MEDICARE: MRS. IMOGENE W CANTRELL

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	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1568523488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IMOGENE W CANTRELL

Provider Business Mailing Address
First Line	:	PO BOX 4618
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31914-0618
Country	:	US
Telephone Number	:	706-660-8877
Fax Number	:	706-660-8877

Provider Business Practice Location Address
First Line	:	1129 13TH ST
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-2248
Country	:	US
Telephone Number	:	706-660-8877
Fax Number	:	706-660-8877

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

Provider Enumeration Date	:	12/13/2006
Last Update Date	:	07/08/2007

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