Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 71264 | CA |
N | 226300000X | Kinesiotherapist | 20203 |
NPI | 1750846432 |
---|---|
Provider Name | Tracey Ethan Bailey |
First Address | Arcadia, CA 91006-5742 |
Second Address | Arcadia, CA 91006-3212 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2019 |
Last Update Date | 07/02/2019 |