1417725896 NPI number — GAVIN MADDOX MASSAGE THERAPIST

Table of content: GAVIN MADDOX MASSAGE THERAPIST (NPI 1417725896)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417725896 NPI number — GAVIN MADDOX MASSAGE THERAPIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADDOX
Provider First Name:
GAVIN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MASSAGE THERAPIST
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417725896
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2230 ROSALIA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FULLERTON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92835-2256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-533-1614
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17672 BEACH BLVD STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HUNTINGTON BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92647-6836
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-533-1614
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/15/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225700000X , with the licence number:  57336 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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