MEDICARE: MR. JUSTIN LONN SPOONER L.P.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	2251X0800X	Orthopedic Physical Therapist	PT2055	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT2055	OTHER	FL	LICENSE #

General Provider Information

NPI Number	:	1134134836
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN LONN SPOONER L.P.T.

Provider Business Mailing Address
First Line	:	621 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984-5141
Country	:	US
Telephone Number	:	772-343-8000
Fax Number	:	772-343-7999

Provider Business Practice Location Address
First Line	:	621 SE PORT ST LUCIE BLVD
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34984-5141
Country	:	US
Telephone Number	:	772-343-8000
Fax Number	:	772-343-7999

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

Provider Enumeration Date	:	07/30/2006
Last Update Date	:	12/09/2009

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