MEDICARE: KELLI MIRR 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	175L00000X	Homeopath	28886	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MA 28886	OTHER	FL	LICENSE MASSAGE THERAPIST

General Provider Information

NPI Number	:	1255660213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLI MIRR LMT

Provider Business Mailing Address
First Line	:	4921 SHERIDAN ST
Second Line	:	SUITE 6
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-2823
Country	:	US
Telephone Number	:	954-924-8878
Fax Number	:

Provider Business Practice Location Address
First Line	:	4921 SHERIDAN ST
Second Line	:	SUITE 6
City	:	HOLLYWOOD
State	:	FL
Zip	:	33021-2823
Country	:	US
Telephone Number	:	954-924-8878
Fax Number	:

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

Provider Enumeration Date	:	12/21/2009
Last Update Date	:	12/21/2009

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