MEDICARE: MR. MARK ALAN FISHER 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	MA16739	FL

General Provider Information

NPI Number	:	1053614073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MARK ALAN FISHER LMT

Provider Business Mailing Address
First Line	:	916 NE 17TH CT
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33305-3127
Country	:	US
Telephone Number	:	954-463-6791
Fax Number	:	954-463-0830

Provider Business Practice Location Address
First Line	:	916 NE 17TH CT
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33305-3127
Country	:	US
Telephone Number	:	954-463-6791
Fax Number	:	954-463-0830

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

Provider Enumeration Date	:	12/13/2010
Last Update Date	:	12/13/2010

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