MEDICARE: ANGISELIS LOURDES FELICIANO MARTELL

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	MT014822	GA

General Provider Information

NPI Number	:	1487467395
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGISELIS LOURDES FELICIANO MARTELL

Provider Business Mailing Address
First Line	:	5093 COPSE DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30909-9850
Country	:	US
Telephone Number	:	984-220-6394
Fax Number	:

Provider Business Practice Location Address
First Line	:	4408 COLUMBIA RD STE 106
Second Line	:
City	:	MARTINEZ
State	:	GA
Zip	:	30907-4561
Country	:	US
Telephone Number	:	984-220-6394
Fax Number	:

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

Provider Enumeration Date	:	01/27/2025
Last Update Date	:	01/27/2025

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