MEDICARE: MERCEDES M MEDINA LMT

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	MA64329	FL

General Provider Information

NPI Number	:	1770865099
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MERCEDES M MEDINA LMT

Provider Business Mailing Address
First Line	:	PO BOX 152521
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33915-2521
Country	:	US
Telephone Number	:	239-240-3118
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 NE 2ND AVE
Second Line	:
City	:	CAPE CORAL
State	:	FL
Zip	:	33909-1208
Country	:	US
Telephone Number	:	239-240-3118
Fax Number	:

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

Provider Enumeration Date	:	09/13/2011
Last Update Date	:	09/13/2011

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