Provider Demographics
NPI:1437715877
Name:TOMCO, KELCEE (LMT)
Entity Type:Individual
Prefix:
First Name:KELCEE
Middle Name:
Last Name:TOMCO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 CABINET VIEW LN
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-6751
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30544 HIGHWAY 200 STE 326
Practice Address - Street 2:
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-5042
Practice Address - Country:US
Practice Address - Phone:208-205-9559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-3787225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDMAS-3787OtherIDAHO MASSAGE LICENSE