MEDICARE: MRS. IRENE G DELEON MASSAGE THERAPIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225700000X	Massage Therapist	MA00015421	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	157584	OTHER		PIN NUMBER

General Provider Information

NPI Number	:	1134323140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IRENE G DELEON MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	1418 S PIONEER WAY
Second Line	:	SUITE E
City	:	MOSES LAKE
State	:	WA
Zip	:	98837
Country	:	US
Telephone Number	:	509-766-1211
Fax Number	:	509-766-6878

Provider Business Practice Location Address
First Line	:	1418 S PIONEER WAY
Second Line	:	SUITE E
City	:	MOSES LAKE
State	:	WA
Zip	:	98837
Country	:	US
Telephone Number	:	509-766-1211
Fax Number	:	509-766-6878

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2007
Last Update Date	:	07/08/2007

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