MEDICARE: MRS. MAUREEN LEE MODER MS, 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	0006317	FL

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	:	1679541262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MAUREEN LEE MODER MS, PT

Provider Business Mailing Address
First Line	:	7900 SW 161ST ST
Second Line	:
City	:	VILLAGE OF PALMETTO BAY
State	:	FL
Zip	:	33157-3737
Country	:	US
Telephone Number	:	305-255-6869
Fax Number	:

Provider Business Practice Location Address
First Line	:	6341 SUNSET DR
Second Line	:
City	:	SOUTH MIAMI
State	:	FL
Zip	:	33143-4842
Country	:	US
Telephone Number	:	305-662-5924
Fax Number	:	305-663-4442

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

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	10/23/2014

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