=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760858831
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NEVIN MICHAEL HAIR L.M.P
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2015
-----------------------------------------------------
Last Update Date | 08/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6314 19TH ST W SUITE# 11
-----------------------------------------------------
City | FIRCREST
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98466-6223
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-267-8188
-----------------------------------------------------
Fax | 253-267-8187
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11502 ASHTON AVE E
-----------------------------------------------------
City | BONNEY LAKE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98391-6144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-737-7173
-----------------------------------------------------
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 | MA 60546704
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------