=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063273803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD DREW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2024
-----------------------------------------------------
Last Update Date | 01/18/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2250 W GLENDALE AVE APT 105
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85021-7766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-249-0610
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15380 W YOUNG ST APT 3029
-----------------------------------------------------
City | SURPRISE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85374-7459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-249-0610
-----------------------------------------------------
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 | MT-29619
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------