MEDICARE: HYRUM RICHARD BERG 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	MA60308870	WA

General Provider Information

NPI Number	:	1770031684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HYRUM RICHARD BERG LMP

Provider Business Mailing Address
First Line	:	2080 SE SEDGWICK RD
Second Line	:	SUITE 200
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-7003
Country	:	US
Telephone Number	:	360-602-0475
Fax Number	:	360-443-6250

Provider Business Practice Location Address
First Line	:	2080 SE SEDGWICK RD
Second Line	:	SUITE 200
City	:	PORT ORCHARD
State	:	WA
Zip	:	98366-7003
Country	:	US
Telephone Number	:	360-602-0475
Fax Number	:	360-443-6250

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

Provider Enumeration Date	:	09/20/2016
Last Update Date	:	09/20/2016

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