MEDICARE: MARJORY LYNN PHILIPPON CLT, RMT

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	2390	CO

General Provider Information

NPI Number	:	1417292426
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARJORY LYNN PHILIPPON CLT, RMT

Provider Business Mailing Address
First Line	:	3270 E 4TH AVE
Second Line	:
City	:	DURANGO
State	:	CO
Zip	:	81301-6002
Country	:	US
Telephone Number	:	970-769-4653
Fax Number	:	970-247-8911

Provider Business Practice Location Address
First Line	:	1537 FLORIDA RD
Second Line	:	SUITE 105
City	:	DURANGO
State	:	CO
Zip	:	81301-5792
Country	:	US
Telephone Number	:	970-385-6708
Fax Number	:	970-247-8911

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

Provider Enumeration Date	:	12/02/2012
Last Update Date	:	09/25/2014

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