MEDICARE: MR. GARRY PEARSON JR.

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	172A00000X	Driver	38267744	NC

General Provider Information

NPI Number	:	1548795651
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GARRY PEARSON JR.

Provider Business Mailing Address
First Line	:	2121 ORANGE BLOSSOM CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-4963
Country	:	US
Telephone Number	:	317-989-1078
Fax Number	:

Provider Business Practice Location Address
First Line	:	2121 ORANGE BLOSSOM CT
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46229-4963
Country	:	US
Telephone Number	:	317-989-1078
Fax Number	:

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

Provider Enumeration Date	:	04/26/2017
Last Update Date	:	04/27/2017

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