MEDICARE: KHA HOANG MA61112149

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	MA61112149	WA

General Provider Information

NPI Number	:	1861065831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KHA HOANG MA61112149

Provider Business Mailing Address
First Line	:	2405 SYCAMORE ST SE
Second Line	:
City	:	LACEY
State	:	WA
Zip	:	98503-3338
Country	:	US
Telephone Number	:	360-878-5726
Fax Number	:

Provider Business Practice Location Address
First Line	:	1412 E YELM AVE STE C101
Second Line	:
City	:	YELM
State	:	WA
Zip	:	98597-8328
Country	:	US
Telephone Number	:	360-458-7533
Fax Number	:

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

Provider Enumeration Date	:	07/19/2021
Last Update Date	:	07/19/2021

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Directions to “ KHA HOANG MA61112149” Practice Location

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