MEDICARE: KIM COLEGROVE

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	225700000X	Massage Therapist	33.015190	OH

General Provider Information

NPI Number	:	1073923256
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIM COLEGROVE

Provider Business Mailing Address
First Line	:	3566 WARREN RD
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44111-3039
Country	:	US
Telephone Number	:	216-287-1358
Fax Number	:

Provider Business Practice Location Address
First Line	:	12501 MADISON AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-5004
Country	:	US
Telephone Number	:	216-287-1358
Fax Number	:

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

Provider Enumeration Date	:	04/28/2014
Last Update Date	:	04/28/2014

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Directions to “ KIM COLEGROVE ” Practice Location

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