MEDICARE: MISS LAUREN ELYSE BLAIR L.M.T

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	MA59939	FL

General Provider Information

NPI Number	:	1720360860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS LAUREN ELYSE BLAIR L.M.T

Provider Business Mailing Address
First Line	:	1291 WINTER GARDEN VINELAND RD
Second Line	:	#130
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-6705
Country	:	US
Telephone Number	:	407-614-5900
Fax Number	:	407-614-5903

Provider Business Practice Location Address
First Line	:	1291 WINTER GARDEN VINELAND RD
Second Line	:	#130
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-6705
Country	:	US
Telephone Number	:	407-614-5900
Fax Number	:	407-614-5903

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

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	09/14/2011

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