MEDICARE: KELLIE DEE ANDERSON MPT

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	225100000X	Physical Therapist	25025	CA

General Provider Information

NPI Number	:	1295939528
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLIE DEE ANDERSON MPT

Provider Business Mailing Address
First Line	:	PO BOX 1243
Second Line	:
City	:	SANGER
State	:	CA
Zip	:	93657-1243
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5180 N PALM AVE
Second Line	:	# 102
City	:	FRESNO
State	:	CA
Zip	:	93704-2229
Country	:	US
Telephone Number	:	559-244-0394
Fax Number	:

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

Provider Enumeration Date	:	06/12/2007
Last Update Date	:	07/08/2007

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