MEDICARE: MR. TERRY LEE CRADDOCK L.M.T, L.P.N.

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		IL

General Provider Information

NPI Number	:	1164605549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TERRY LEE CRADDOCK L.M.T, L.P.N.

Provider Business Mailing Address
First Line	:	120 S MAIN ST
Second Line	:
City	:	FARMER CITY
State	:	IL
Zip	:	61842-1454
Country	:	US
Telephone Number	:	309-824-4373
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 S MAIN ST
Second Line	:
City	:	FARMER CITY
State	:	IL
Zip	:	61842-1454
Country	:	US
Telephone Number	:	309-824-4373
Fax Number	:

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

Provider Enumeration Date	:	12/09/2007
Last Update Date	:	01/10/2008

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