Provider Demographics
NPI:1083505598
Name:PELLETIER, MICHAEL C (BCOM, MBA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:C
Last Name:PELLETIER
Suffix:
Gender:M
Credentials:BCOM, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 GALLEON ST
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5904
Mailing Address - Country:US
Mailing Address - Phone:310-913-5652
Mailing Address - Fax:
Practice Address - Street 1:116 GALLEON ST
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5904
Practice Address - Country:US
Practice Address - Phone:310-913-5652
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-12
Last Update Date:2025-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator