Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 29634 | CA |
NPI | 1003429408 |
---|---|
Provider Name | Michelle Boller |
First Address | San Diego, CA 92103-6080 |
Second Address | San Diego, CA 92103-1804 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2020 |
Last Update Date | 25/08/2020 |