=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083274674
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILA M WITTER LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2019
-----------------------------------------------------
Last Update Date | 06/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 872 TROY RD STE 170
-----------------------------------------------------
City | MOSCOW
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83843-4046
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-892-6506
-----------------------------------------------------
Fax | 509-334-6768
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1256 SE BISHOP BLVD STE J
-----------------------------------------------------
City | PULLMAN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99163-5414
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-332-6506
-----------------------------------------------------
Fax | 509-334-6768
-----------------------------------------------------
=====================================================
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 | MAS3163
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------