=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376831305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WESLEY C KALITOVIC LMP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2011
-----------------------------------------------------
Last Update Date | 07/12/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1800 BICKFORD AVE STE 201
-----------------------------------------------------
City | SNOHOMISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98290-1769
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-319-1123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1309 39TH ST
-----------------------------------------------------
City | EVERETT
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98201-4806
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-218-9753
-----------------------------------------------------
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 | MA 60214967
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------