Healthcare Provider Details

I. General information

NPI: 1235642422
Provider Name (Legal Business Name): THOMAS MAYNARD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 11/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26545 MAPLE VALLEY BLACK DIAMOND RD SE STE K160
MAPLE VALLEY WA
98038-8391
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 253-284-9800
  • Fax: 253-284-9801
Mailing address:
  • Phone: 630-296-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: