MEDICARE: MS. KENNETTE LESLIE OLDHAM MASSAGE THERAPIST

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	10508	CO

General Provider Information

NPI Number	:	1285979369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KENNETTE LESLIE OLDHAM MASSAGE THERAPIST

Provider Business Mailing Address
First Line	:	126 W D ST STE 100C
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-4430
Country	:	US
Telephone Number	:	719-250-7675
Fax Number	:	719-545-2807

Provider Business Practice Location Address
First Line	:	126 W D ST STE 100C
Second Line	:
City	:	PUEBLO
State	:	CO
Zip	:	81003-4430
Country	:	US
Telephone Number	:	719-250-7675
Fax Number	:	719-545-2807

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

Provider Enumeration Date	:	11/30/2012
Last Update Date	:	11/30/2012

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