MEDICARE: TAMMY OWEIDA WILSON LMT

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	172M00000X	Mechanotherapist	014227	OH

General Provider Information

NPI Number	:	1265866461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMMY OWEIDA WILSON LMT

Provider Business Mailing Address
First Line	:	217 AARON CT
Second Line	:
City	:	DELAWARE
State	:	OH
Zip	:	43015-3334
Country	:	US
Telephone Number	:	740-417-9221
Fax Number	:

Provider Business Practice Location Address
First Line	:	161 S LIBERTY ST
Second Line	:
City	:	POWELL
State	:	OH
Zip	:	43065-7619
Country	:	US
Telephone Number	:	614-306-2494
Fax Number	:

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

Provider Enumeration Date	:	08/25/2013
Last Update Date	:	08/25/2013

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