=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588993901
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SPENCER DWIGHT DUNN LICENSED MASSAGE PRA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/14/2009
-----------------------------------------------------
Last Update Date | 12/14/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 NE GRACE AVE LMP MOBIL SERVICE OR
-----------------------------------------------------
City | BATTLE GROUND
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-687-5163
-----------------------------------------------------
Fax | 360-687-5165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 820502
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-326-4325
-----------------------------------------------------
Fax | 360-326-4325
-----------------------------------------------------
=====================================================
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 | MA00023028
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------