MEDICARE: MRS. JUDITH W GAYLORD

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	171M00000X	Case Manager/Care Coordinator	130	AR

General Provider Information

NPI Number	:	1316185754
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUDITH W GAYLORD

Provider Business Mailing Address
First Line	:	219 N DUDNEY RD
Second Line	:
City	:	MAGNOLIA
State	:	AR
Zip	:	71753-3110
Country	:	US
Telephone Number	:	870-234-2425
Fax Number	:

Provider Business Practice Location Address
First Line	:	219 N DUDNEY RD
Second Line	:
City	:	MAGNOLIA
State	:	AR
Zip	:	71753-3110
Country	:	US
Telephone Number	:	870-234-2425
Fax Number	:

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

Provider Enumeration Date	:	01/22/2009
Last Update Date	:	01/22/2009

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