MEDICARE: BRENT G BINGHAM 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	225700000X	Massage Therapist	MT00834	AZ
2	225700000X	Massage Therapist	6735789-4701	UT

General Provider Information

NPI Number	:	1841451424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENT G BINGHAM LMT

Provider Business Mailing Address
First Line	:	5525 N 19TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-3004
Country	:	US
Telephone Number	:	928-961-4837
Fax Number	:

Provider Business Practice Location Address
First Line	:	5525 N 19TH ST
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85016-3004
Country	:	US
Telephone Number	:	928-961-4837
Fax Number	:

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

Provider Enumeration Date	:	06/17/2008
Last Update Date	:	02/18/2014

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Directions to “ BRENT G BINGHAM LMT” Practice Location

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