MEDICARE: MR. ISAAC LORD PT

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	2895	NM

General Provider Information

NPI Number	:	1710972690
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ISAAC LORD PT

Provider Business Mailing Address
First Line	:	PO BOX 386
Second Line	:
City	:	COALVILLE
State	:	UT
Zip	:	84017-0386
Country	:	US
Telephone Number	:	575-545-1223
Fax Number	:

Provider Business Practice Location Address
First Line	:	462 N MAIN ST
Second Line	:
City	:	COALVILLE
State	:	UT
Zip	:	84017-9777
Country	:	US
Telephone Number	:	575-545-1223
Fax Number	:

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

Provider Enumeration Date	:	09/15/2005
Last Update Date	:	10/26/2010

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