MEDICARE: MICHELLE L MANDICH 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	MA51120	FL

General Provider Information

NPI Number	:	1134422173
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE L MANDICH LMT

Provider Business Mailing Address
First Line	:	3636 DEL PRADO BLVD S.
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33904
Country	:	US
Telephone Number	:	239-540-5560
Fax Number	:	239-540-0270

Provider Business Practice Location Address
First Line	:	3636 DEL PRADO BLVD S.
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33904
Country	:	US
Telephone Number	:	239-540-5560
Fax Number	:	239-540-0270

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

Provider Enumeration Date	:	12/14/2010
Last Update Date	:	12/20/2010

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