MEDICARE: DEREK A TAFOYA LMP

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	MA601315960	WA

General Provider Information

NPI Number	:	1386943140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEREK A TAFOYA LMP

Provider Business Mailing Address
First Line	:	7803 NE 332ND ST
Second Line	:
City	:	LA CENTER
State	:	WA
Zip	:	98629-2721
Country	:	US
Telephone Number	:	360-448-8056
Fax Number	:

Provider Business Practice Location Address
First Line	:	7803 NE 332ND ST
Second Line	:
City	:	LA CENTER
State	:	WA
Zip	:	98629-2721
Country	:	US
Telephone Number	:	360-448-8056
Fax Number	:

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

Provider Enumeration Date	:	03/19/2011
Last Update Date	:	03/19/2011

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