Healthcare Provider Details

I. General information

NPI: 1871381004
Provider Name (Legal Business Name): GARY FLYGARE LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14410 SE PETROVITSKY RD STE 109
RENTON WA
98058-8900
US

IV. Provider business mailing address

26625 ORVILLE RD E
ORTING WA
98360-9753
US

V. Phone/Fax

Practice location:
  • Phone: 425-226-1856
  • Fax:
Mailing address:
  • Phone: 253-324-6930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number60815501
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: