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General NPI Number Information
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NPI Number | 1679295679
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Entity Type | Organization
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Legal Business Name | MOBILE MASSAGE PRO PLLC
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Dates
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Enumeration Date | 09/15/2022
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Last Update Date | 09/15/2022
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Provider Practice Location Address
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Address Line | 21407 W BAKER RD
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City | CHENEY
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State | WA
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Zip | 99004-9160
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Country | US
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Telephone | 253-327-8719
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Fax |
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Provider Business Mailing Address
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Address Line | 21407 W BAKER RD
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City | CHENEY
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State | WA
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Zip | 99004-9160
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Country | US
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Telephone | 253-327-8719
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Fax |
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Authorized Official
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Title or Position | OWNER/ THERAPIST
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Name | KEVIN LIDDLE II
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Credential | LMT
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Telephone | 360-605-0680
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number |
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License Number State |
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