Basic Information
| Provider Information | |||||||||
| NPI: | 1538650239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | THOMAS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | CMT, HHP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23285 CAMINITO MARCIAL | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926531621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495476427 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1202 BRISTOL ST FL 2 | ||||||||
| Address2: | |||||||||
| City: | COSTA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926268605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144249001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2018 | ||||||||
| LastUpdateDate: | 05/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | 62792 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | 62792 | 01 | CA | CAMTC | OTHER |