MEDICARE: MR. DEREK J DELAMOTTE LPN

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	164W00000X	Licensed Practical Nurse	PN-100619-IV	OH

General Provider Information

NPI Number	:	1750569067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEREK J DELAMOTTE LPN

Provider Business Mailing Address
First Line	:	2800 TUDOR RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-3004
Country	:	US
Telephone Number	:	614-235-6373
Fax Number	:

Provider Business Practice Location Address
First Line	:	2800 TUDOR RD
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43209-3004
Country	:	US
Telephone Number	:	614-235-6373
Fax Number	:

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

Provider Enumeration Date	:	02/08/2008
Last Update Date	:	02/08/2008

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