Healthcare Provider Details

I. General information

NPI: 1194719906
Provider Name (Legal Business Name): JESUS O DELA TORRE HERNANDEZ LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6985 COAL CREEK PKWY SE
NEWCASTLE WA
98059-3136
US

IV. Provider business mailing address

PO BOX 731269
PUYALLUP WA
98373-0060
US

V. Phone/Fax

Practice location:
  • Phone: 425-378-0500
  • Fax: 425-378-8168
Mailing address:
  • Phone: 253-840-2313
  • Fax: 253-840-6340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00021328
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: