=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740879956
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | IDRIS THOMAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2021
-----------------------------------------------------
Last Update Date | 01/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 589 S SPAULDING AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-840-0687
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 589 S SPAULDING AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90036-3202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-840-0687
-----------------------------------------------------
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 | 85052
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------