MEDICARE: BRIAN VANDEMORTEL 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	015813	NY

General Provider Information

NPI Number	:	1568422715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN VANDEMORTEL LMT

Provider Business Mailing Address
First Line	:	1072 EVERWILD VW
Second Line	:
City	:	WEBSTER
State	:	NY
Zip	:	14580-8741
Country	:	US
Telephone Number	:	585-872-3256
Fax Number	:

Provider Business Practice Location Address
First Line	:	40 NORTH AVE
Second Line	:
City	:	WEBSTER
State	:	NY
Zip	:	14580-3056
Country	:	US
Telephone Number	:	585-329-0887
Fax Number	:

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

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	07/08/2007

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