Provider Demographics
NPI:1447018841
Name:EVERAGE, SEAN ANTHONY
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:ANTHONY
Last Name:EVERAGE
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 1:14213 DRESSAGE RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92394-7605
Mailing Address - Country:US
Mailing Address - Phone:425-595-0302
Mailing Address - Fax:
Practice Address - Street 1:26001 REDLANDS BLVD
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-7762
Practice Address - Country:US
Practice Address - Phone:909-825-7084
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA76641225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist