MEDICARE: MR. BRYCE KUULEI DOMINGO PTA, 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	225200000X	Physical Therapy Assistant
2	225700000X	Massage Therapist	MA00024952	WA

General Provider Information

NPI Number	:	1528175445
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRYCE KUULEI DOMINGO PTA, LMP

Provider Business Mailing Address
First Line	:	1940 S BONITO WAY STE 190
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-5618
Country	:	US
Telephone Number	:	208-287-9420
Fax Number	:

Provider Business Practice Location Address
First Line	:	17833 1ST AVE S STE A
Second Line	:
City	:	NORMANDY PARK
State	:	WA
Zip	:	98148-1713
Country	:	US
Telephone Number	:	253-330-8518
Fax Number	:

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

Provider Enumeration Date	:	08/24/2006
Last Update Date	:	03/20/2023

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