=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366004434
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGEL DE LA PAZ MASSAGE THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2019
-----------------------------------------------------
Last Update Date | 06/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 E EVERGREEN BLVD STE 322A
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98660-3385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 369-953-1350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7110 NE 43RD ST APT A
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98661-3651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSE ANGEL DE LA PAZ
-----------------------------------------------------
Credential | LMT
-----------------------------------------------------
Telephone | 360-953-1350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------