=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588024335
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | REBBECCA LYNN BISHOP CMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/07/2016
-----------------------------------------------------
Last Update Date | 03/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1897 E COLTON AVE INSIDE CROSSFIT EAST REDLANDS
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-9797
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-353-7786
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1721 E COLTON AVE SPC 118
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-4968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-674-4733
-----------------------------------------------------
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 | 53553
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------