MEDICARE: MS. STACIE L GRIFFIN 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	174400000X	Specialist	MA#41848	FL

General Provider Information

NPI Number	:	1407170061
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. STACIE L GRIFFIN LMT

Provider Business Mailing Address
First Line	:	201 EDGEWOOD DR
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-2413
Country	:	US
Telephone Number	:	407-414-6111
Fax Number	:

Provider Business Practice Location Address
First Line	:	255 W HIGHWAY 50
Second Line	:
City	:	CLERMONT
State	:	FL
Zip	:	34711-3027
Country	:	US
Telephone Number	:	352-394-4615
Fax Number	:

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

Provider Enumeration Date	:	03/25/2010
Last Update Date	:	03/25/2010

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