MEDICARE: MRS. SARA DAUGHTRY MCCLAIN P.T.A.

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	225200000X	Physical Therapy Assistant	21431	FL
2	225700000X	Massage Therapist	35852	FL

General Provider Information

NPI Number	:	1467607903
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SARA DAUGHTRY MCCLAIN P.T.A.

Provider Business Mailing Address
First Line	:	289 SW STONEGATE TER
Second Line	:	SUITE 101
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3457
Country	:	US
Telephone Number	:	386-755-3164
Fax Number	:	386-755-3165

Provider Business Practice Location Address
First Line	:	289 SW STONEGATE TER
Second Line	:	SUITE 101
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3457
Country	:	US
Telephone Number	:	386-755-3164
Fax Number	:	386-755-3165

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

Provider Enumeration Date	:	11/25/2008
Last Update Date	:	11/25/2008

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