Basic Information
| Provider Information | |||||||||
| NPI: | 1437799863 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGER | ||||||||
| FirstName: | DMITRY | ||||||||
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| Credential: | LMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 SW EVERETT MALL WAY STE G | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982042715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253555222 | ||||||||
| FaxNumber: | 4253555231 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 120TH AVE NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980053024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256880223 | ||||||||
| FaxNumber: | 4256889323 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2020 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA61019709 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |
ID Information
| ID | Type | State | Issuer | Description | MA61019709 | 01 | WA | WA STATE LICENSE | OTHER |