MEDICARE: MISS BRISDELI GARCIA MALDONADO

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	MA60871099	WA

General Provider Information

NPI Number	:	1851874028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS BRISDELI GARCIA MALDONADO

Provider Business Mailing Address
First Line	:	907 HARRINGTON AVE NE APT 4
Second Line	:
City	:	RENTON
State	:	WA
Zip	:	98056-3076
Country	:	US
Telephone Number	:	206-259-0023
Fax Number	:

Provider Business Practice Location Address
First Line	:	10242 16TH AVE SW
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98146-1432
Country	:	US
Telephone Number	:	206-764-9600
Fax Number	:

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

Provider Enumeration Date	:	09/12/2018
Last Update Date	:	09/12/2018

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