MEDICARE: MR. THOMAS BREITBARTH

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	227.000305	IL

General Provider Information

NPI Number	:	1306255989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS BREITBARTH

Provider Business Mailing Address
First Line	:	1713 FORT JESSE RD
Second Line	:	SUITE D
City	:	NORMAL
State	:	IL
Zip	:	61761-6208
Country	:	US
Telephone Number	:	309-862-2225
Fax Number	:	309-862-2229

Provider Business Practice Location Address
First Line	:	1713 FORT JESSE RD
Second Line	:	SUITE D
City	:	NORMAL
State	:	IL
Zip	:	61761-6208
Country	:	US
Telephone Number	:	309-862-2225
Fax Number	:	309-862-2229

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

Provider Enumeration Date	:	08/07/2014
Last Update Date	:	08/07/2014

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