MEDICARE: DALE G WANDEN 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	MA00024926	WA

General Provider Information

NPI Number	:	1497907364
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DALE G WANDEN LMP

Provider Business Mailing Address
First Line	:	815 RYAN AVE
Second Line	:
City	:	SUMNER
State	:	WA
Zip	:	98390-1428
Country	:	US
Telephone Number	:	253-282-2450
Fax Number	:

Provider Business Practice Location Address
First Line	:	1140 140TH AVE NE STE A
Second Line	:
City	:	BELLEVUE
State	:	WA
Zip	:	98005-2975
Country	:	US
Telephone Number	:	425-957-0761
Fax Number	:	425-957-1156

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

Provider Enumeration Date	:	10/22/2008
Last Update Date	:	10/22/2008

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Directions to “ DALE G WANDEN LMP” Practice Location

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