=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609362243
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. EE BEAN HIAM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2018
-----------------------------------------------------
Last Update Date | 07/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 63 E SPAULDING AVE # W113
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007-5416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-470-1047
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 955 S CAYUGA DR
-----------------------------------------------------
City | PUEBLO WEST
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81007-1919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-470-1047
-----------------------------------------------------
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 | 0020422
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------