Active NPI
Mark Edward Vennerholm II, CMT
- Massage Therapist
- Vista, CA
National Provider Identifier
1053012443
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Massage Therapist
- License
- 93040
- Practice address
- 2305 S Melrose Dr Ste 103
Vista, CA 92081-8789 - Phone
- (760) 230-3898
- NPI assigned
- Mar 13, 2023
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Massage Therapist | 225700000X | 93040 | CA | Primary |
Addresses
Primary practice location
2305 S Melrose Dr Ste 103
Vista, CA 92081-8789
Mailing address
208 B Ave Apt a
Coronado, CA 92118-1998
Phone (940) 206-1838
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 93040 | CA | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1678665600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1678665600000",
"number": "1053012443",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "208 B AVE APT A",
"city": "CORONADO",
"state": "CA",
"postal_code": "921181998",
"telephone_number": "940-206-1838"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2305 S MELROSE DR STE 103",
"city": "VISTA",
"state": "CA",
"postal_code": "920818789",
"telephone_number": "760-230-3898"
}
],
"practiceLocations": [],
"basic": {
"last_name": "VENNERHOLM",
"first_name": "MARK",
"middle_name": "EDWARD",
"name_prefix": "Mr.",
"name_suffix": "II",
"credential": "CMT",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2023-03-13",
"last_updated": "2023-03-13",
"certification_date": "2023-03-13",
"status": "A"
},
"taxonomies": [
{
"code": "225700000X",
"taxonomy_group": "",
"desc": "Massage Therapist",
"state": "CA",
"license": "93040",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Vista, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 13, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.