MEDICARE: RENEE SUPPES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	18-00546	KS

General Provider Information

NPI Number	:	1013119684
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE SUPPES

Provider Business Mailing Address
First Line	:	2400 CHEYENNE DR
Second Line	:
City	:	GREAT BEND
State	:	KS
Zip	:	67530-2437
Country	:	US
Telephone Number	:	620-791-8677
Fax Number	:

Provider Business Practice Location Address
First Line	:	402 N SANTA FE ST
Second Line	:
City	:	SAINT JOHN
State	:	KS
Zip	:	67576-1800
Country	:	US
Telephone Number	:	615-896-6400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/08/2007

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