MEDICARE: JOE DAVID SECREST IV LMT

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	MT120063	TX

General Provider Information

NPI Number	:	1083991780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOE DAVID SECREST IV LMT

Provider Business Mailing Address
First Line	:	5800 EDWARDS RANCH RD STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4126
Country	:	US
Telephone Number	:	843-345-3271
Fax Number	:

Provider Business Practice Location Address
First Line	:	5800 EDWARDS RANCH RD STE 200
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76109-4126
Country	:	US
Telephone Number	:	843-345-3271
Fax Number	:

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

Provider Enumeration Date	:	11/08/2011
Last Update Date	:	12/31/2018

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