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NPI Code Detail

MEDICARE: KEVIN PENNELL L.M.T.

MEDICARE: KEVIN PENNELL 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
1225700000XMassage TherapistMT4495ME

General Provider Information

NPI Number : 1386064848
Entity Type Code : Individual
Provider Name (Legal Business Name) : KEVIN PENNELL L.M.T.
Provider Business Mailing Address
First Line : 95 BOOTHBY AVE
Second Line :
City : SOUTH PORTLAND
State : ME
Zip : 04106-4628
Country : US
Telephone Number : 207-577-1010
Fax Number :
Provider Business Practice Location Address
First Line : 55 WARREN AVE
Second Line :
City : PORTLAND
State : ME
Zip : 04103-1103
Country : US
Telephone Number : 207-577-1010
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/23/2014
Last Update Date : 04/23/2014

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Directions to “ KEVIN PENNELL L.M.T.” Practice Location

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