MEDICARE: TRACIE LORIECE SIPPLE PT

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	2646	NM

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00348972	OTHER	NM	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2646	OTHER	NM	STATE OF NM REG & LICENS.
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205836707
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE LORIECE SIPPLE PT

Provider Business Mailing Address
First Line	:	PO BOX 504
Second Line	:
City	:	LAFOX
State	:	IL
Zip	:	60147
Country	:	US
Telephone Number	:	505-220-3401
Fax Number	:

Provider Business Practice Location Address
First Line	:	312 E READER ST
Second Line	:
City	:	ELBURN
State	:	IL
Zip	:	60119
Country	:	US
Telephone Number	:	505-220-3401
Fax Number	:

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

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	03/22/2021

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Directions to “ TRACIE LORIECE SIPPLE PT” Practice Location

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