MEDICARE: DR. TIMOTHY LEWIS BOURNE DPT

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	PTH6268	AL

General Provider Information

NPI Number	:	1326320375
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY LEWIS BOURNE DPT

Provider Business Mailing Address
First Line	:	636 COUNTY ROAD 852
Second Line	:
City	:	FORT PAYNE
State	:	AL
Zip	:	35967-5739
Country	:	US
Telephone Number	:	256-572-2522
Fax Number	:

Provider Business Practice Location Address
First Line	:	636 COUNTY ROAD 852
Second Line	:
City	:	FORT PAYNE
State	:	AL
Zip	:	35967-5739
Country	:	US
Telephone Number	:	256-572-2522
Fax Number	:

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

Provider Enumeration Date	:	09/15/2011
Last Update Date	:	09/15/2011

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