MEDICARE: MR. ROBERT A. SANDEFUR NCMMT

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	174400000X	Specialist

General Provider Information

NPI Number	:	1306061544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT A. SANDEFUR NCMMT

Provider Business Mailing Address
First Line	:	226 SIDNEY ST
Second Line	:
City	:	DUNDEE
State	:	MI
Zip	:	48131-1267
Country	:	US
Telephone Number	:	734-529-5138
Fax Number	:	734-529-5626

Provider Business Practice Location Address
First Line	:	226 SIDNEY ST
Second Line	:
City	:	DUNDEE
State	:	MI
Zip	:	48131-1267
Country	:	US
Telephone Number	:	734-529-5138
Fax Number	:	734-529-5626

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

Provider Enumeration Date	:	04/14/2007
Last Update Date	:	07/08/2007

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