MEDICARE: GLENNA MARIA PRIETO MSPT

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	225100000X	Physical Therapist	001730	GA

General Provider Information

NPI Number	:	1144266529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENNA MARIA PRIETO MSPT

Provider Business Mailing Address
First Line	:	108 CLEARWATER DR
Second Line	:
City	:	LAGRANGE
State	:	GA
Zip	:	30241-1524
Country	:	US
Telephone Number	:	706-885-0912
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 17TH ST
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-3500
Country	:	US
Telephone Number	:	706-321-0930
Fax Number	:

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

Provider Enumeration Date	:	06/22/2006
Last Update Date	:	07/08/2007

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