MEDICARE: TERRALAR J LEE LMT

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	MA60730523	WA

General Provider Information

NPI Number	:	1922662493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERRALAR J LEE LMT

Provider Business Mailing Address
First Line	:	PO BOX 926
Second Line	:
City	:	LONG BEACH
State	:	WA
Zip	:	98631-0926
Country	:	US
Telephone Number	:	360-642-3278
Fax Number	:

Provider Business Practice Location Address
First Line	:	113 OREGON AVE S
Second Line	:
City	:	LONG BEACH
State	:	WA
Zip	:	98631-3988
Country	:	US
Telephone Number	:	360-642-3278
Fax Number	:

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

Provider Enumeration Date	:	04/30/2019
Last Update Date	:	04/30/2019

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