MEDICARE: JANE HOUSE RPT

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	225100000X	Physical Therapist	001128	CT

General Provider Information

NPI Number	:	1053465237
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JANE HOUSE RPT

Provider Business Mailing Address
First Line	:	701 COTTAGE GROVE RD
Second Line	:	E130
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3059
Country	:	US
Telephone Number	:	860-286-0838
Fax Number	:	860-286-0109

Provider Business Practice Location Address
First Line	:	701 COTTAGE GROVE RD
Second Line	:	SUITE E130
City	:	BLOOMFIELD
State	:	CT
Zip	:	06002-3059
Country	:	US
Telephone Number	:	860-286-0838
Fax Number	:

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

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	07/08/2007

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