MEDICARE: MARIA LEAH E MONTECILLO PT

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	225100000X	Physical Therapist	2846	SC

General Provider Information

NPI Number	:	1598847360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA LEAH E MONTECILLO PT

Provider Business Mailing Address
First Line	:	PO BOX 369
Second Line	:
City	:	SIMPSONVILLE
State	:	SC
Zip	:	29681-0369
Country	:	US
Telephone Number	:	864-329-4211
Fax Number	:	678-840-2112

Provider Business Practice Location Address
First Line	:	213 E BUTLER RD BLDG E2
Second Line	:
City	:	MAULDIN
State	:	SC
Zip	:	29662-2172
Country	:	US
Telephone Number	:	864-346-0391
Fax Number	:	678-840-2112

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

Provider Enumeration Date	:	10/20/2006
Last Update Date	:	07/08/2007

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