MEDICARE: MS. TIMOTHY H ADDERLEY

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	172V00000X	Community Health Worker		FL

General Provider Information

NPI Number	:	1811160260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TIMOTHY H ADDERLEY

Provider Business Mailing Address
First Line	:	2518 OLEANDER BLVD
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5814
Country	:	US
Telephone Number	:	772-467-9765
Fax Number	:

Provider Business Practice Location Address
First Line	:	2518 OLEANDER BLVD
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34982-5814
Country	:	US
Telephone Number	:	772-467-9765
Fax Number	:

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

Provider Enumeration Date	:	04/07/2008
Last Update Date	:	04/07/2008

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