Healthcare Provider Details

I. General information

NPI: 1063652493
Provider Name (Legal Business Name): DIANE LEE GEIGER LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2009
Last Update Date: 02/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 W ROBERT BUSH DR BOX 211
SOUTH BEND WA
98586
US

IV. Provider business mailing address

1010 W ROBERT BUSH DRIVE P O BOX 211
SOUTH BEND WA
98586
US

V. Phone/Fax

Practice location:
  • Phone: 360-875-5543
  • Fax: 360-875-5544
Mailing address:
  • Phone: 360-875-5543
  • Fax: 360-875-5544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA00017701
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: