Basic Information
| Provider Information | |||||||||
| NPI: | 1023550589 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SALDIVAR | ||||||||
| FirstName: | EGMONT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 361 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094883346 | ||||||||
| FaxNumber: | 5094883347 | ||||||||
| Practice Location | |||||||||
| Address1: | 361 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | OTHELLO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993441055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094883346 | ||||||||
| FaxNumber: | 5094883347 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2016 | ||||||||
| LastUpdateDate: | 11/14/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00017915 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.