MEDICARE: MR. LEO TAGBAR SUMATRA

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	2251G0304X	Geriatric Physical Therapist	PT1965	TN

General Provider Information

NPI Number	:	1497017578
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LEO TAGBAR SUMATRA

Provider Business Mailing Address
First Line	:	13135 LEBANON RD
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-2873
Country	:	US
Telephone Number	:	615-554-9224
Fax Number	:

Provider Business Practice Location Address
First Line	:	13135 LEBANON RD
Second Line	:
City	:	MOUNT JULIET
State	:	TN
Zip	:	37122-2873
Country	:	US
Telephone Number	:	615-554-9224
Fax Number	:

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

Provider Enumeration Date	:	06/13/2012
Last Update Date	:	06/13/2012

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