Healthcare Provider Details

I. General information

NPI: 1386943140
Provider Name (Legal Business Name): DEREK A TAFOYA LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2011
Last Update Date: 03/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7803 NE 332ND ST
LA CENTER WA
98629-2721
US

IV. Provider business mailing address

7803 NE 332ND ST
LA CENTER WA
98629-2721
US

V. Phone/Fax

Practice location:
  • Phone: 360-448-8056
  • Fax:
Mailing address:
  • Phone: 360-448-8056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA601315960
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: