Provider Demographics
NPI:1871821702
Name:HUMPHREYS, IRAS
Entity Type:Individual
Prefix:MS
First Name:IRAS
Middle Name:
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10705 N LINDEN RD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:WI
Mailing Address - Zip Code:54843-4047
Mailing Address - Country:US
Mailing Address - Phone:715-634-2560
Mailing Address - Fax:
Practice Address - Street 1:10705 N LINDEN RD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:WI
Practice Address - Zip Code:54843-4047
Practice Address - Country:US
Practice Address - Phone:715-634-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-04
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4752046OtherMASSAGE THERAPIST