MEDICARE: DANIEL P BAGWELL 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	174400000X	Specialist	MT0016705	CO

General Provider Information

NPI Number	:	1710382817
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL P BAGWELL LMT

Provider Business Mailing Address
First Line	:	2226 STAFFORD LANE
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80909
Country	:	US
Telephone Number	:	678-787-1886
Fax Number	:	719-531-0880

Provider Business Practice Location Address
First Line	:	2620 TENDERFOOT HILL ST
Second Line	:	SUITE 200
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80906-8353
Country	:	US
Telephone Number	:	719-527-6747
Fax Number	:	719-531-0880

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

Provider Enumeration Date	:	10/31/2014
Last Update Date	:	10/31/2014

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