MEDICARE: KELLY MCGUIRE LPTA

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	2306000687	VA

General Provider Information

NPI Number	:	1578769469
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MCGUIRE LPTA

Provider Business Mailing Address
First Line	:	2468 MIRROR LAKE DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23453-3716
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2135 GENERAL BOOTH BLVD STE 152
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5881
Country	:	US
Telephone Number	:	757-438-8828
Fax Number	:	757-430-8189

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

Provider Enumeration Date	:	06/26/2007
Last Update Date	:	07/08/2007

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