Active NPI
Charles Wallace Niesen III, LMP
- Massage Therapist
- Port Orchard, WA
National Provider Identifier
1407048903
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Massage Therapist
- License
- MA00018507
- Practice address
- 7950 State Highway 3 SW
Port Orchard, WA 98367-9149 - Phone
- (360) 801-1295
- NPI assigned
- Aug 17, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Massage Therapist | 225700000X | MA00018507 | WA | Primary |
Addresses
Primary practice location
7950 State Highway 3 SW
Port Orchard, WA 98367-9149
Mailing address
PO Box 252
Belfair, WA 98528-0252
Phone (360) 801-1295
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| MA00018507 | WA | MD | Massage Therapist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1187308800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1187308800000",
"number": "1407048903",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 252",
"city": "BELFAIR",
"state": "WA",
"postal_code": "985280252",
"telephone_number": "360-801-1295"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "7950 STATE HIGHWAY 3 SW",
"city": "PORT ORCHARD",
"state": "WA",
"postal_code": "983679149",
"telephone_number": "360-801-1295"
}
],
"practiceLocations": [],
"basic": {
"last_name": "NIESEN",
"first_name": "CHARLES",
"middle_name": "WALLACE",
"name_prefix": "Mr.",
"name_suffix": "III",
"credential": "LMP",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-08-17",
"last_updated": "2007-08-17",
"status": "A"
},
"taxonomies": [
{
"code": "225700000X",
"taxonomy_group": "",
"desc": "Massage Therapist",
"state": "WA",
"license": "MA00018507",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Port Orchard, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 17, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.