MEDICARE: KELLY SUTTON L.M.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	174400000X	Specialist	MA52881	FL

General Provider Information

NPI Number	:	1073825220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY SUTTON L.M.T.

Provider Business Mailing Address
First Line	:	2611 WHITEWOOD RD
Second Line	:
City	:	MULBERRY
State	:	FL
Zip	:	33860-5508
Country	:	US
Telephone Number	:	863-669-7363
Fax Number	:

Provider Business Practice Location Address
First Line	:	4325 HIGHLAND PARK BLVD
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-1671
Country	:	US
Telephone Number	:	863-669-7363
Fax Number	:	863-647-1793

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

Provider Enumeration Date	:	07/04/2010
Last Update Date	:	07/04/2010

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