Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225700000X | Massage Therapist | 67507 | CA |
NPI | 1003421686 |
---|---|
Provider Name | Rick Bryce Tyson |
First Address | Vallejo, CA 94590-6270 |
Second Address | Vallejo, CA 94590-6270 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/09/2020 |
Last Update Date | 10/09/2020 |