=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710306022
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS BENJAMIN HALVORSON LMP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/15/2014
-----------------------------------------------------
Last Update Date | 04/15/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5609 S LAWRENCE ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98409-5319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-380-2685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3933 S 302ND ST
-----------------------------------------------------
City | AUBURN
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98001-2225
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-380-2685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number | MA60457447
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------