MEDICARE: DARCI M DUSPIVA 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	602 889 889	WA

General Provider Information

NPI Number	:	1861624561
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARCI M DUSPIVA LMP

Provider Business Mailing Address
First Line	:	5834 S BAYVIEW RD
Second Line	:
City	:	CLINTON
State	:	WA
Zip	:	98236
Country	:	US
Telephone Number	:	360-969-1051
Fax Number	:

Provider Business Practice Location Address
First Line	:	11042 SR 525 # SUIET106
Second Line	:
City	:	CLINTON
State	:	WA
Zip	:	98236-8618
Country	:	US
Telephone Number	:	360-341-1299
Fax Number	:

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

Provider Enumeration Date	:	08/13/2009
Last Update Date	:	08/13/2009

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