Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 2017040934 | MO |
NPI | 1003306648 |
---|---|
Provider Name | Don Russell Swift |
First Address | Prairie Village, KS 66207-2715 |
Second Address | Prairie Village, KS 66207-2715 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/05/2018 |
Last Update Date | 16/06/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
2017040934 | MISSOURI BOARD OF THERAPEUTIC MASSAGE (01) | MO |