Provider Demographics
NPI:1316548456
Name:CONCEICAO, PAULO
Entity type:Individual
Prefix:
First Name:PAULO
Middle Name:
Last Name:CONCEICAO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6559 COMLY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5401
Mailing Address - Country:US
Mailing Address - Phone:574-276-9728
Mailing Address - Fax:
Practice Address - Street 1:6559 COMLY ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-5401
Practice Address - Country:US
Practice Address - Phone:574-276-9728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-05
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59333225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist