=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003421686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICK BRYCE TYSON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/10/2020
-----------------------------------------------------
Last Update Date | 09/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 YORK ST APT A
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-6270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-676-0478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 YORK ST APT A
-----------------------------------------------------
City | VALLEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94590-6270
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-676-0478
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 67507
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------