MEDICARE: MRS. IRENE TAN LU RPT

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	PT20719	FL

General Provider Information

NPI Number	:	1811016140
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. IRENE TAN LU RPT

Provider Business Mailing Address
First Line	:	3749 CABALLERO AVE
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-6966
Country	:	US
Telephone Number	:	941-876-6888
Fax Number	:

Provider Business Practice Location Address
First Line	:	3749 CABALLERO AVE
Second Line	:
City	:	NORTH PORT
State	:	FL
Zip	:	34286-6966
Country	:	US
Telephone Number	:	941-876-6888
Fax Number	:

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

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	07/08/2007

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