MEDICARE: MICHELLE ANGELO DPT

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	225100000X	Physical Therapist	6511	SC

General Provider Information

NPI Number	:	1700102498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE ANGELO DPT

Provider Business Mailing Address
First Line	:	307 74TH AVENUE NORTH
Second Line	:	#4B
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572
Country	:	US
Telephone Number	:	203-231-9505
Fax Number	:

Provider Business Practice Location Address
First Line	:	307 74TH AVE N
Second Line	:	#4B
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29572-3837
Country	:	US
Telephone Number	:	203-231-9505
Fax Number	:

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

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	04/20/2010

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