MEDICARE: LANCE MICHAEL SUPNET DPT

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

General Provider Information

NPI Number	:	1093558173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LANCE MICHAEL SUPNET DPT

Provider Business Mailing Address
First Line	:	3099 WHITESAND DR
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95148-3056
Country	:	US
Telephone Number	:	408-513-5820
Fax Number	:

Provider Business Practice Location Address
First Line	:	4205 SAN FELIPE RD STE 100
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95135-1546
Country	:	US
Telephone Number	:	408-238-1552
Fax Number	:

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

Provider Enumeration Date	:	06/17/2024
Last Update Date	:	06/17/2024

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