MEDICARE: RAY BLOUNT LNMT

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	MT000031	GA

General Provider Information

NPI Number	:	1144455536
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAY BLOUNT LNMT

Provider Business Mailing Address
First Line	:	2175 LENOX RD NE
Second Line	:	C4
City	:	ATLANTA
State	:	GA
Zip	:	30324-4733
Country	:	US
Telephone Number	:	404-226-3590
Fax Number	:

Provider Business Practice Location Address
First Line	:	1874 PIEDMONT RD NE
Second Line	:	480D
City	:	ATLANTA
State	:	GA
Zip	:	30324-4869
Country	:	US
Telephone Number	:	404-226-3590
Fax Number	:

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

Provider Enumeration Date	:	05/28/2009
Last Update Date	:	05/28/2009

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