MEDICARE: RYAN WITHOLT LMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	3291	NV

General Provider Information

NPI Number	:	1043690852
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN WITHOLT LMT

Provider Business Mailing Address
First Line	:	6222 FOOTHILL BLVD
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89118-1455
Country	:	US
Telephone Number	:	702-505-1494
Fax Number	:

Provider Business Practice Location Address
First Line	:	4005 S EL CAPITAN WAY
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-3430
Country	:	US
Telephone Number	:	170-275-1600
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2015
Last Update Date	:	06/05/2015

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