Healthcare Provider Details

I. General information

NPI: 1639435639
Provider Name (Legal Business Name): ALEX GWOZDA LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

943 N 89TH ST
SEATTLE WA
98103-3905
US

IV. Provider business mailing address

1902 N 80TH ST
SEATTLE WA
98103-4504
US

V. Phone/Fax

Practice location:
  • Phone: 206-390-7465
  • Fax:
Mailing address:
  • Phone: 206-390-7465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60214970
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: