=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730565318
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TAKE TEN BODYWORKS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2015
-----------------------------------------------------
Last Update Date | 08/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 N LAKE SURF DR
-----------------------------------------------------
City | LILLIWAUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98555-9786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-683-5565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 N LAKE SURF DR
-----------------------------------------------------
City | LILLIWAUP
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98555-9786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-683-5565
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ALEXIS A VAUGHAN
-----------------------------------------------------
Credential | LMP/LMT
-----------------------------------------------------
Telephone | 206-683-5565
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172M00000X
-----------------------------------------------------
Taxonomy Name | Mechanotherapist
-----------------------------------------------------
License Number | MA00019372
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------