MEDICARE: LARA CHILTON CMT

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	MT21104206	IN

General Provider Information

NPI Number	:	1104342732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARA CHILTON CMT

Provider Business Mailing Address
First Line	:	5909 NASH LN
Second Line	:
City	:	SPEEDWAY
State	:	IN
Zip	:	46224-5310
Country	:	US
Telephone Number	:	317-441-3824
Fax Number	:

Provider Business Practice Location Address
First Line	:	2250 W 86TH ST STE 100
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46260-1965
Country	:	US
Telephone Number	:	317-876-7826
Fax Number	:

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

Provider Enumeration Date	:	08/15/2017
Last Update Date	:	08/15/2017

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