MEDICARE: BRENDA K KNOWLES 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	MA25096	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C2645	OTHER	FL	BCBSFL

General Provider Information

NPI Number	:	1134215213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA K KNOWLES LMT

Provider Business Mailing Address
First Line	:	4570 SAN JUAN AVE
Second Line	:	SUITE 2
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-2051
Country	:	US
Telephone Number	:	904-388-8844
Fax Number	:	904-389-1170

Provider Business Practice Location Address
First Line	:	4570 SAN JUAN AVE
Second Line	:	SUITE 2
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-2051
Country	:	US
Telephone Number	:	904-388-8844
Fax Number	:	904-389-1170

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

Provider Enumeration Date	:	10/05/2006
Last Update Date	:	07/08/2007

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Directions to “ BRENDA K KNOWLES LMT” Practice Location

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