Provider Demographics
NPI:1770621245
Name:SAUCKE, KENNETH D (LMP)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:D
Last Name:SAUCKE
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:MR
Other - First Name:KEN
Other - Middle Name:D
Other - Last Name:SAUCKE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMP
Mailing Address - Street 1:PO BOX 11009
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-1009
Mailing Address - Country:US
Mailing Address - Phone:360-352-2037
Mailing Address - Fax:360-292-7247
Practice Address - Street 1:3333 HARRISON AVE NW
Practice Address - Street 2:SUITE 102
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-5049
Practice Address - Country:US
Practice Address - Phone:360-292-7245
Practice Address - Fax:360-292-7247
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017335171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA00017335OtherMASSAGE PRACTICIONER