MEDICARE: JUSTIN ERTEL-REDFIELD 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	172M00000X	Mechanotherapist	028258-1	NY

General Provider Information

NPI Number	:	1578917365
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN ERTEL-REDFIELD LMT

Provider Business Mailing Address
First Line	:	8600 MAIN ST.
Second Line	:	SUITE 2
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221
Country	:	US
Telephone Number	:	716-616-9000
Fax Number	:	716-408-3222

Provider Business Practice Location Address
First Line	:	8600 MAIN ST
Second Line	:	SUITE 2
City	:	WILLIAMSVILLE
State	:	NY
Zip	:	14221-7464
Country	:	US
Telephone Number	:	716-616-9000
Fax Number	:	716-408-3222

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

Provider Enumeration Date	:	04/18/2016
Last Update Date	:	04/18/2016

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