=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558608679
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKALAUS LOYD LAYMON LCM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2013
-----------------------------------------------------
Last Update Date | 01/09/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 860 RALPH HALL PKWY #46
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75032
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-598-0273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 WILLOW RIDGE CIR
-----------------------------------------------------
City | ROCKWALL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75032-9121
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-694-0463
-----------------------------------------------------
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 | 115597
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------