Provider Demographics
NPI:1902042211
Name:CASEBERE, JOHN S II (LMP)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:S
Last Name:CASEBERE
Suffix:II
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5962
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0962
Mailing Address - Country:US
Mailing Address - Phone:253-229-7074
Mailing Address - Fax:253-473-3807
Practice Address - Street 1:4026 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98418-7830
Practice Address - Country:US
Practice Address - Phone:253-229-7074
Practice Address - Fax:253-473-1142
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00010173225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACA4591OtherREGENCE BLUE SHIELD