Healthcare Provider Details

I. General information

NPI: 1437715877
Provider Name (Legal Business Name): KELCEE TOMCO LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HIGHWAY 200 STE 326
PONDERAY ID
83852-5042
US

IV. Provider business mailing address

408 CABINET VIEW LN
SANDPOINT ID
83864-6751
US

V. Phone/Fax

Practice location:
  • Phone: 208-205-9559
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMAS-3787
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: