=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851569008
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANA RICHARD PETERSON LMP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/11/2008
-----------------------------------------------------
Last Update Date | 02/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5915 S REGAL ST STE B218
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99223-6970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-499-1652
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2622 E 61ST AVE
-----------------------------------------------------
City | SPOKANE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 99223-6912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 509-448-3977
-----------------------------------------------------
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 | MA00024873
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------