Provider Demographics
NPI:1285056549
Name:DOLPH, CYRUS SAN NICOLAS (LMP)
Entity type:Individual
Prefix:MR
First Name:CYRUS
Middle Name:SAN NICOLAS
Last Name:DOLPH
Suffix:
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 1:9212 N ELLENWOOD CT
Mailing Address - Street 2:
Mailing Address - City:NINE MILE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:99026-9206
Mailing Address - Country:US
Mailing Address - Phone:509-990-6595
Mailing Address - Fax:
Practice Address - Street 1:9212 N ELLENWOOD CT
Practice Address - Street 2:
Practice Address - City:NINE MILE FALLS
Practice Address - State:WA
Practice Address - Zip Code:99026-9206
Practice Address - Country:US
Practice Address - Phone:509-990-6595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60420401225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist