MEDICARE: MISS BETHANY D COBURN 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	3769	NM

General Provider Information

NPI Number	:	1679730311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS BETHANY D COBURN LMT

Provider Business Mailing Address
First Line	:	11517 HANNETT AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-4413
Country	:	US
Telephone Number	:	505-417-4167
Fax Number	:

Provider Business Practice Location Address
First Line	:	11517 HANNETT AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87112-4413
Country	:	US
Telephone Number	:	505-417-4167
Fax Number	:

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

Provider Enumeration Date	:	05/20/2008
Last Update Date	:	12/07/2016

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