=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710748827
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN A THOMAS LMT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2024
-----------------------------------------------------
Last Update Date | 01/17/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21315 33RD RD
-----------------------------------------------------
City | BAYSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11361-1508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-962-0799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19510B PECK AVE # 10B
-----------------------------------------------------
City | FRESH MEADOWS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11365-2857
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-256-5906
-----------------------------------------------------
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 | 032238
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------