Basic Information
| Provider Information | |||||||||
| NPI: | 1912386152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VENEGAS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | WESLEIGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | III | ||||||||
| Credential: | LMP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 NW GILMAN BLVD | ||||||||
| Address2: | STE. A | ||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980272446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254276562 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 680 NW GILMAN BLVD | ||||||||
| Address2: | STE. A | ||||||||
| City: | ISSAQUAH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980272446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254276562 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2015 | ||||||||
| LastUpdateDate: | 05/20/2015 | ||||||||
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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 | MA60562022 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
No ID Information.