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NPI Code Detail

MEDICARE: MRS. MELINDA ELISE SMITH L.M.T. , M.M.P

MEDICARE: MRS. MELINDA ELISE SMITH L.M.T. , M.M.P
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
1174400000XSpecialistMT209000676IN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MT209000676OTHERINMASSAGE THERAPY LICENSE NUMBER

General Provider Information

NPI Number : 1598168197
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. MELINDA ELISE SMITH L.M.T. , M.M.P
Provider Business Mailing Address
First Line : 4821 FOXGROVE AVE
Second Line :
City : FORT WAYNE
State : IN
Zip : 46818-2029
Country : US
Telephone Number : 260-246-9963
Fax Number :
Provider Business Practice Location Address
First Line : 5812 MAPLECREST RD
Second Line :
City : FORT WAYNE
State : IN
Zip : 46835-3840
Country : US
Telephone Number : 260-969-7977
Fax Number : 260-969-6590
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/27/2014
Last Update Date : 09/27/2014

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