MEDICARE: MR. RICHARD IVAN HISER LMP

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	MA60393455	WA

General Provider Information

NPI Number	:	1285064998
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD IVAN HISER LMP

Provider Business Mailing Address
First Line	:	151 ISLAND BOULEVARD FI
Second Line	:
City	:	FOX ISLAND
State	:	WA
Zip	:	98333-9753
Country	:	US
Telephone Number	:	253-283-6061
Fax Number	:

Provider Business Practice Location Address
First Line	:	151 ISLAND BLVD
Second Line	:
City	:	FOX ISLAND
State	:	WA
Zip	:	98333-9753
Country	:	US
Telephone Number	:	253-283-6061
Fax Number	:

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

Provider Enumeration Date	:	11/15/2013
Last Update Date	:	11/15/2013

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