MEDICARE: MR. JUSTIN MICHAEL SHAY I L.M.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	174400000X	Specialist	006164	CT

General Provider Information

NPI Number	:	1134406382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JUSTIN MICHAEL SHAY I L.M.T

Provider Business Mailing Address
First Line	:	81 NASH LN # 6
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06605-3017
Country	:	US
Telephone Number	:	203-212-0278
Fax Number	:

Provider Business Practice Location Address
First Line	:	2889 FAIRFIELD AVE
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06605-3211
Country	:	US
Telephone Number	:	203-212-0278
Fax Number	:

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

Provider Enumeration Date	:	11/15/2011
Last Update Date	:	11/15/2011

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