MEDICARE: KRYSTAL GLASSCOCK 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	MA 73686	FL

General Provider Information

NPI Number	:	1457744799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRYSTAL GLASSCOCK LMT

Provider Business Mailing Address
First Line	:	100 CABANA CAY CIR
Second Line	:	SUITE 206
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-4662
Country	:	US
Telephone Number	:	850-691-7187
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 CABANA CAY CIR
Second Line	:	SUITE 206
City	:	PANAMA CITY BEACH
State	:	FL
Zip	:	32413-4662
Country	:	US
Telephone Number	:	850-691-7187
Fax Number	:

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

Provider Enumeration Date	:	03/11/2015
Last Update Date	:	03/11/2015

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