Basic Information
| Provider Information | |||||||||
| NPI: | 1770621245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SAUCKE | ||||||||
| FirstName: | KENNETH | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LMP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SAUCKE | ||||||||
| OtherFirstName: | KEN | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMP | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 11009 | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985081009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603522037 | ||||||||
| FaxNumber: | 3602927247 | ||||||||
| Practice Location | |||||||||
| Address1: | 3333 HARRISON AVE NW | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985025049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602927245 | ||||||||
| FaxNumber: | 3602927247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2007 | ||||||||
| LastUpdateDate: | 01/11/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171W00000X | MA00017335 | WA | Y | Other Service Providers | Contractor |
ID Information
| ID | Type | State | Issuer | Description | MA00017335 | 01 | WA | MASSAGE PRACTICIONER | OTHER |