Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist |
NPI | 1003464645 |
---|---|
Provider Name | Jed Bentley |
First Address | Orinda, CA 94563-1916 |
Second Address | San Francisco, CA 94114-2511 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/08/2019 |
Last Update Date | 27/08/2019 |