MEDICARE: MRS. TERI LEE SMITH LMT

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	MA0019085	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	C8116	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1386796977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TERI LEE SMITH LMT

Provider Business Mailing Address
First Line	:	1003 S ALEXANDER ST
Second Line	:	SUITE 4
City	:	PLANT CITY
State	:	FL
Zip	:	33563-8400
Country	:	US
Telephone Number	:	813-719-1963
Fax Number	:	813-719-1963

Provider Business Practice Location Address
First Line	:	1003 S ALEXANDER ST
Second Line	:	SUITE 4
City	:	PLANT CITY
State	:	FL
Zip	:	33563-8400
Country	:	US
Telephone Number	:	813-719-1963
Fax Number	:	813-719-1963

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

Provider Enumeration Date	:	01/17/2007
Last Update Date	:	07/08/2007

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