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NPI Code Detail

MEDICARE: IRENE MARDAL LMT

MEDICARE: IRENE MARDAL 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
1225700000XMassage Therapist000932CT

General Provider Information

NPI Number : 1396108270
Entity Type Code : Individual
Provider Name (Legal Business Name) : IRENE MARDAL LMT
Provider Business Mailing Address
First Line : 26 WOOSTER ST
Second Line : APARTMENT REAR
City : BETHEL
State : CT
Zip : 06801-1832
Country : US
Telephone Number : 203-448-9184
Fax Number :
Provider Business Practice Location Address
First Line : 100 REDDING RD
Second Line :
City : REDDING
State : CT
Zip : 06896-3236
Country : US
Telephone Number : 203-544-7733
Fax Number : 203-544-1200
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/30/2016
Last Update Date : 03/30/2016

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