MEDICARE: DR. CRISTI LEE BOULDIN DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	SC006148	PA
2	213ES0103X	Foot & Ankle Surgery Podiatrist	727	TN

General Provider Information

NPI Number	:	1649403080
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CRISTI LEE BOULDIN DPM

Provider Business Mailing Address
First Line	:	108 N SPRING ST
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-1563
Country	:	US
Telephone Number	:	931-728-3988
Fax Number	:	931-728-6530

Provider Business Practice Location Address
First Line	:	108 N SPRING ST
Second Line	:
City	:	MANCHESTER
State	:	TN
Zip	:	37355-1563
Country	:	US
Telephone Number	:	931-728-3988
Fax Number	:	931-728-6530

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

Provider Enumeration Date	:	09/02/2009
Last Update Date	:	07/26/2012

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