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General NPI Number Information
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NPI Number | 1710008206
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Entity Type | Organization
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Legal Business Name | KEIRA WIDMER
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Dates
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Enumeration Date | 04/02/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 5440 S LAKESHORE DR SUITE 101
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City | TEMPE
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State | AZ
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Zip | 85283-2101
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Country | US
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Telephone | 480-628-8089
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 10667
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City | TEMPE
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State | AZ
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Zip | 85284-0012
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Country | US
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Telephone | 480-628-8089
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MS. KEIRA WIDMER
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Credential | LMT, CST, RYT
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Telephone | 480-628-8089
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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 | MT03104P
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License Number State | AZ
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