Healthcare Provider Details

I. General information

NPI: 1619402625
Provider Name (Legal Business Name): TRENT A TELLIER LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2017
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19102 STATE ROUTE 410 E STE A
BONNEY LAKE WA
98391-8449
US

IV. Provider business mailing address

11311 216TH AVE E
BONNEY LAKE WA
98391-7847
US

V. Phone/Fax

Practice location:
  • Phone: 253-863-6378
  • Fax: 253-863-6429
Mailing address:
  • Phone: 253-318-8789
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 60475814
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: