Healthcare Provider Details

I. General information

NPI: 1417149105
Provider Name (Legal Business Name): GARY GLENN RHODES JR. LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5410 CALIFORNIA AVE SW SUITE 203
SEATTLE WA
98136-1562
US

IV. Provider business mailing address

5410 CALIFORNIA AVE SW SUITE 203
SEATTLE WA
98136-1562
US

V. Phone/Fax

Practice location:
  • Phone: 206-331-3999
  • Fax: 206-388-3226
Mailing address:
  • Phone: 206-331-3999
  • Fax: 206-388-3226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number#MA00023439
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: