MEDICARE: DR. CAMERON PELLETIER DPT

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	225100000X	Physical Therapist	5585	NM

General Provider Information

NPI Number	:	1457970519
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAMERON PELLETIER DPT

Provider Business Mailing Address
First Line	:	3402 BIXLER DR APT 204
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-5108
Country	:	US
Telephone Number	:	843-576-9054
Fax Number	:

Provider Business Practice Location Address
First Line	:	3402 BIXLER DR APT 204
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88012-5108
Country	:	US
Telephone Number	:	843-576-9054
Fax Number	:

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

Provider Enumeration Date	:	04/09/2020
Last Update Date	:	04/09/2020

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