MEDICARE: KELLY MCNABB BURGENSTOCK

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	27030	FL

General Provider Information

NPI Number	:	1730389420
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY MCNABB BURGENSTOCK

Provider Business Mailing Address
First Line	:	16 JOINER STREET
Second Line	:
City	:	WINTER GARDEN
State	:	FL
Zip	:	34787-4204
Country	:	US
Telephone Number	:	321-945-7030
Fax Number	:

Provider Business Practice Location Address
First Line	:	1816 PRAIRIE LAKE BLVD
Second Line	:
City	:	OCOEE
State	:	FL
Zip	:	34761
Country	:	US
Telephone Number	:	321-945-7030
Fax Number	:

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

Provider Enumeration Date	:	07/20/2007
Last Update Date	:	03/01/2012

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