MEDICARE: KAREN WINE NMT

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	MT005071	GA

General Provider Information

NPI Number	:	1144549528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN WINE NMT

Provider Business Mailing Address
First Line	:	5068 HIDDEN BRANCH DR
Second Line	:
City	:	SUGAR HILL
State	:	GA
Zip	:	30518-4674
Country	:	US
Telephone Number	:	404-644-1641
Fax Number	:

Provider Business Practice Location Address
First Line	:	5068 HIDDEN BRANCH DR
Second Line	:
City	:	SUGAR HILL
State	:	GA
Zip	:	30518-4674
Country	:	US
Telephone Number	:	404-644-1641
Fax Number	:

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

Provider Enumeration Date	:	05/24/2010
Last Update Date	:	05/24/2010

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