MEDICARE: MRS. SARA JANE SMITH RKT

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	226300000X	Kinesiotherapist	955	OH

General Provider Information

NPI Number	:	1265653075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARA JANE SMITH RKT

Provider Business Mailing Address
First Line	:	54 CHATHAM ROAD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214
Country	:	US
Telephone Number	:	614-262-9963
Fax Number	:

Provider Business Practice Location Address
First Line	:	54 CHATHAM ROAD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214
Country	:	US
Telephone Number	:	614-262-9963
Fax Number	:

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

Provider Enumeration Date	:	05/01/2007
Last Update Date	:	07/08/2007

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