MEDICARE: MR. RANDALL LEE KENYON 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	MA00013417	WA

General Provider Information

NPI Number	:	1528114840
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDALL LEE KENYON LMP

Provider Business Mailing Address
First Line	:	1605 12TH AVE
Second Line	:	STE. #20
City	:	SEATTLE
State	:	WA
Zip	:	98122-2467
Country	:	US
Telephone Number	:	206-227-8301
Fax Number	:

Provider Business Practice Location Address
First Line	:	1605 12TH AVE
Second Line	:	STE. #20
City	:	SEATTLE
State	:	WA
Zip	:	98122-2467
Country	:	US
Telephone Number	:	206-227-8301
Fax Number	:

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

Provider Enumeration Date	:	01/27/2007
Last Update Date	:	07/08/2007

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