Provider Demographics
NPI:1760805071
Name:BHUMIYAM
Entity Type:Organization
Organization Name:BHUMIYAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MASSAGE THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:A
Authorized Official - Last Name:GREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-713-9631
Mailing Address - Street 1:PO BOX 96
Mailing Address - Street 2:
Mailing Address - City:SKULL VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86338-0096
Mailing Address - Country:US
Mailing Address - Phone:928-713-9631
Mailing Address - Fax:
Practice Address - Street 1:634 SCHEMMER DR STE 301
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-2368
Practice Address - Country:US
Practice Address - Phone:928-713-9631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-23
Last Update Date:2014-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-10655302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization