MEDICARE: MR. ADAM LEE WAUGH MPO, CO

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	222Z00000X	Orthotist	213.000354	IL

General Provider Information

NPI Number	:	1487176293
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ADAM LEE WAUGH MPO, CO

Provider Business Mailing Address
First Line	:	17530 DUGDALE DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1583
Country	:	US
Telephone Number	:	574-233-3352
Fax Number	:

Provider Business Practice Location Address
First Line	:	17530 DUGDALE DR
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46635-1583
Country	:	US
Telephone Number	:	574-233-3352
Fax Number	:

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

Provider Enumeration Date	:	07/13/2017
Last Update Date	:	07/13/2017

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