MEDICARE: ANDERSON DAVID THEODORE 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	MT006637	GA

General Provider Information

NPI Number	:	1639031222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDERSON DAVID THEODORE LMT

Provider Business Mailing Address
First Line	:	5412 ROCK LAKE DR
Second Line	:
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-8905
Country	:	US
Telephone Number	:	678-644-7357
Fax Number	:

Provider Business Practice Location Address
First Line	:	5412 ROCK LAKE DR
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-8905
Country	:	US
Telephone Number	:	678-644-7357
Fax Number	:

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

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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