MEDICARE: ELIZABETH W PRINCE 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	PT001140	GA

General Provider Information

NPI Number	:	1518046937
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH W PRINCE PT

Provider Business Mailing Address
First Line	:	3798 BERMUDA RUN DR
Second Line	:
City	:	VALDOSTA
State	:	GA
Zip	:	31605-1060
Country	:	US
Telephone Number	:	229-460-4630
Fax Number	:	229-245-6561

Provider Business Practice Location Address
First Line	:	4916 PRINCESS DR
Second Line	:
City	:	LAKE PARK
State	:	GA
Zip	:	31636-3120
Country	:	US
Telephone Number	:	229-460-4630
Fax Number	:

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

Provider Enumeration Date	:	11/05/2006
Last Update Date	:	07/08/2007

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