Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 75510 | CA |
NPI | 1003409624 |
---|---|
Provider Name | Mr. Victor Ray Villa |
First Address | Baldwin Park, CA 91706-4500 |
Second Address | Baldwin Park, CA 91706-4500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/02/2021 |
Last Update Date | 15/02/2021 |