MEDICARE: ABBY M LANE P.T.

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	112589	MO

General Provider Information

NPI Number	:	1871619262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ABBY M LANE P.T.

Provider Business Mailing Address
First Line	:	30251 LAUREL PL
Second Line	:
City	:	MACON
State	:	MO
Zip	:	63552-3802
Country	:	US
Telephone Number	:	660-385-1374
Fax Number	:

Provider Business Practice Location Address
First Line	:	2005 N. MISSOURI ST.
Second Line	:	SUITE D
City	:	MACON
State	:	MO
Zip	:	63552-0387
Country	:	US
Telephone Number	:	660-385-6540
Fax Number	:	660-385-6542

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

Provider Enumeration Date	:	03/21/2007
Last Update Date	:	07/24/2009

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