MEDICARE: MS. GINA BANDONI LMT #2511, CKT

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	2511	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2511	OTHER	NM	LMT

General Provider Information

NPI Number	:	1528251550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GINA BANDONI LMT #2511, CKT

Provider Business Mailing Address
First Line	:	6337 AVENIDA LA COSTA NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87109-4103
Country	:	US
Telephone Number	:	505-440-7424
Fax Number	:

Provider Business Practice Location Address
First Line	:	2509 VERMONT ST NE STE C-3102
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87110-4688
Country	:	US
Telephone Number	:	505-440-7424
Fax Number	:

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

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	04/17/2014

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