MEDICARE: MRS. SHANNON IRENE SMITH

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	10364	SC

General Provider Information

NPI Number	:	1972188027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHANNON IRENE SMITH

Provider Business Mailing Address
First Line	:	131 MAYLAND CT
Second Line	:
City	:	IRMO
State	:	SC
Zip	:	29063-2116
Country	:	US
Telephone Number	:	803-238-9464
Fax Number	:

Provider Business Practice Location Address
First Line	:	1625 LAKE MURRAY BLVD
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29212-8626
Country	:	US
Telephone Number	:	803-238-9464
Fax Number	:

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

Provider Enumeration Date	:	03/10/2021
Last Update Date	:	03/10/2021

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