MEDICARE: CHARLOTTE JEAN PENDLETON LMP

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	MA10264	WA
2	225700000X	Massage Therapist	MA46099	FL

General Provider Information

NPI Number	:	1265874218
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHARLOTTE JEAN PENDLETON LMP

Provider Business Mailing Address
First Line	:	3329 QUEEN PALM DR
Second Line	:
City	:	EDGEWATER
State	:	FL
Zip	:	32141-6624
Country	:	US
Telephone Number	:	386-402-6555
Fax Number	:

Provider Business Practice Location Address
First Line	:	1420 5TH AVE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98101-4087
Country	:	US
Telephone Number	:	206-682-1424
Fax Number	:

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

Provider Enumeration Date	:	07/18/2013
Last Update Date	:	07/18/2013

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