MEDICARE: MS. SANDRA LEE TATE L.M.T.

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	2010-2672	WV

General Provider Information

NPI Number	:	1407167349
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SANDRA LEE TATE L.M.T.

Provider Business Mailing Address
First Line	:	203 MARKET ST
Second Line	:
City	:	MANNINGTON
State	:	WV
Zip	:	26582-1132
Country	:	US
Telephone Number	:	304-986-1008
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 MARKET ST
Second Line	:
City	:	MANNINGTON
State	:	WV
Zip	:	26582-1132
Country	:	US
Telephone Number	:	304-986-1008
Fax Number	:

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

Provider Enumeration Date	:	06/25/2010
Last Update Date	:	06/25/2010

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