MEDICARE: MR. MATTHEW THOMAS GRUBB L.M.T.

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	MA21745	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C8328	OTHER	FL	BLUE CROSS BLUE SHIELD PR

General Provider Information

NPI Number	:	1235151234
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW THOMAS GRUBB L.M.T.

Provider Business Mailing Address
First Line	:	1206 SW MAIN BLVD
Second Line	:	SUITE 103
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6684
Country	:	US
Telephone Number	:	386-719-2500
Fax Number	:	386-719-2500

Provider Business Practice Location Address
First Line	:	1206 SW MAIN BLVD
Second Line	:	SUITE 103
City	:	LAKE CITY
State	:	FL
Zip	:	32025-6684
Country	:	US
Telephone Number	:	386-719-2500
Fax Number	:	386-719-2500

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

Provider Enumeration Date	:	07/25/2006
Last Update Date	:	04/14/2010

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