MEDICARE: MR. BRUCE ALLEN GONSETH SR. 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	MA59342	FL

General Provider Information

NPI Number	:	1548574221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRUCE ALLEN GONSETH SR. LMT

Provider Business Mailing Address
First Line	:	23222 NE 159TH AVE
Second Line	:
City	:	FORT MC COY
State	:	FL
Zip	:	32134-8359
Country	:	US
Telephone Number	:	352-546-5659
Fax Number	:	352-369-1122

Provider Business Practice Location Address
First Line	:	611 NE 25TH AVE
Second Line	:
City	:	OCALA
State	:	FL
Zip	:	34470-7033
Country	:	US
Telephone Number	:	352-362-9469
Fax Number	:	352-369-1122

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

Provider Enumeration Date	:	08/04/2010
Last Update Date	:	08/04/2010

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