MEDICARE: TABITHA MACON

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	MT003205	GA

General Provider Information

NPI Number	:	1316563059
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TABITHA MACON

Provider Business Mailing Address
First Line	:	2045 DUTCHESS RD
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-2312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2045 DUTCHESS RD
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-2312
Country	:	US
Telephone Number	:	770-356-9703
Fax Number	:

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

Provider Enumeration Date	:	06/18/2020
Last Update Date	:	06/18/2020

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Directions to “ TABITHA MACON ” Practice Location

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