MEDICARE: BEVERLY DAZO

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	05008389A	IN

General Provider Information

NPI Number	:	1760584676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BEVERLY DAZO

Provider Business Mailing Address
First Line	:	405 S MORRISON RD APT 63
Second Line	:
City	:	MUNCIE
State	:	IN
Zip	:	47304-4011
Country	:	US
Telephone Number	:	812-620-3883
Fax Number	:

Provider Business Practice Location Address
First Line	:	5980 W 71ST ST STE 201
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46278-1785
Country	:	US
Telephone Number	:	317-388-0800
Fax Number	:

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

Provider Enumeration Date	:	09/01/2006
Last Update Date	:	07/08/2007

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Directions to “ BEVERLY DAZO ” Practice Location

Language	Start Address	Practice Location

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