MEDICARE: DOROTHEA P. FONG LMT, NHD

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	1370M	NH
2	261QH0100X	Health Service Clinic/Center	1370M	NH

General Provider Information

NPI Number	:	1619116050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOROTHEA P. FONG LMT, NHD

Provider Business Mailing Address
First Line	:	42 PINE VALLEY ST
Second Line	:
City	:	WILTON
State	:	NH
Zip	:	03086-5511
Country	:	US
Telephone Number	:	603-654-9697
Fax Number	:

Provider Business Practice Location Address
First Line	:	43 MAIN STREET 2ND FLOOR
Second Line	:
City	:	WILTON
State	:	NH
Zip	:	03086-5511
Country	:	US
Telephone Number	:	603-654-9697
Fax Number	:

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

Provider Enumeration Date	:	02/09/2009
Last Update Date	:	02/09/2009

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