MEDICARE: SUSAN BROCK L.M.T.

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	MT001483	GA

General Provider Information

NPI Number	:	1366855132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN BROCK L.M.T.

Provider Business Mailing Address
First Line	:	3260 VINEVILLE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2324
Country	:	US
Telephone Number	:	478-960-6366
Fax Number	:

Provider Business Practice Location Address
First Line	:	3260 VINEVILLE AVE
Second Line	:
City	:	MACON
State	:	GA
Zip	:	31204-2324
Country	:	US
Telephone Number	:	478-960-6366
Fax Number	:

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

Provider Enumeration Date	:	06/09/2014
Last Update Date	:	06/09/2014

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