MEDICARE: MS. MARY A LANGE 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	MA0012657	FL

General Provider Information

NPI Number	:	1093837650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY A LANGE LMT

Provider Business Mailing Address
First Line	:	PO BOX 1853
Second Line	:
City	:	FLAGLER BEACH
State	:	FL
Zip	:	32136-1853
Country	:	US
Telephone Number	:	386-439-6933
Fax Number	:	386-439-6605

Provider Business Practice Location Address
First Line	:	210 MOODY BLVD
Second Line	:
City	:	FLAGLER BEACH
State	:	FL
Zip	:	32136-3372
Country	:	US
Telephone Number	:	386-439-6933
Fax Number	:	386-439-6605

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

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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