=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558751636
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CELSO RANGEL JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2015
-----------------------------------------------------
Last Update Date | 01/28/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1635 OLYMPIC HWY N
-----------------------------------------------------
City | SHELTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98584-3065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-426-8060
-----------------------------------------------------
Fax | 360-427-5819
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2176
-----------------------------------------------------
City | SHELTON
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98584-5047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-426-8060
-----------------------------------------------------
Fax | 360-427-5819
-----------------------------------------------------
=====================================================
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 | MA60533051
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------