MEDICARE: MR. NATHANIEL FUENTES 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
1	225700000X	Massage Therapist	4071	NM

General Provider Information

NPI Number	:	1487983904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NATHANIEL FUENTES LMT

Provider Business Mailing Address
First Line	:	510 N PASEO DE ONATE
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2618
Country	:	US
Telephone Number	:	505-753-3369
Fax Number	:	505-753-4006

Provider Business Practice Location Address
First Line	:	510 N PASEO DE ONATE
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2618
Country	:	US
Telephone Number	:	505-753-3369
Fax Number	:	505-753-4006

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

Provider Enumeration Date	:	12/11/2009
Last Update Date	:	12/11/2009

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