MEDICARE: EXPERIENCE LEMIEUX

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	335E00000X	Prosthetic/Orthotic Supplier

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	839670	OTHER	PA	LLC

General Provider Information

NPI Number	:	1750900114
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPERIENCE LEMIEUX

Provider Business Mailing Address
First Line	:	900 N 19TH ST UNIT 3247
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-1561
Country	:	US
Telephone Number	:	267-997-1096
Fax Number	:	855-375-7029

Provider Business Practice Location Address
First Line	:	900 N 19TH ST UNIT 3247
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-1561
Country	:	US
Telephone Number	:	267-997-1096
Fax Number	:	855-375-7029

Authorized Official
Title or Position	:	OWNER
Name	:	MS. ASHLEY EDWARDS
Credential	:
Telephone Number	:	267-997-1096

Provider Enumeration Date	:	04/15/2020
Last Update Date	:	04/15/2020

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Directions to “EXPERIENCE LEMIEUX ” Practice Location

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