MEDICARE: LEO R CREDIT JR. PT

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	PT1116	ME

General Provider Information

NPI Number	:	1477509115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEO R CREDIT JR. PT

Provider Business Mailing Address
First Line	:	PO BOX 1047
Second Line	:
City	:	GRAY
State	:	ME
Zip	:	04039-1047
Country	:	US
Telephone Number	:	207-657-5600
Fax Number	:	207-657-5620

Provider Business Practice Location Address
First Line	:	6 TURNPIKE ACRES RD
Second Line	:
City	:	GRAY
State	:	ME
Zip	:	04039-9432
Country	:	US
Telephone Number	:	207-657-5600
Fax Number	:	207-657-5620

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

Provider Enumeration Date	:	05/25/2006
Last Update Date	:	03/29/2013

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