Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 77079 | CA |
NPI | 1003408410 |
---|---|
Provider Name | Roberto Hernal |
First Address | Rosemead, CA 91770-2111 |
Second Address | Los Angeles, CA 90065-3667 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/02/2021 |
Last Update Date | 06/10/2021 |