MEDICARE: MR. JONATHAN GALLUP GALLUP 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	MA52036	FL

General Provider Information

NPI Number	:	1093992059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JONATHAN GALLUP GALLUP LMT

Provider Business Mailing Address
First Line	:	25334 JUBAL ST
Second Line	:
City	:	PUNTA GORDA
State	:	FL
Zip	:	33955-4251
Country	:	US
Telephone Number	:	941-575-7636
Fax Number	:

Provider Business Practice Location Address
First Line	:	2212 CLEVELAND AVE
Second Line	:
City	:	FORT MYERS
State	:	FL
Zip	:	33901-3501
Country	:	US
Telephone Number	:	941-268-9653
Fax Number	:

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

Provider Enumeration Date	:	01/22/2008
Last Update Date	:	01/22/2008

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