MEDICARE: MS. KELLY JO MARTINDALE 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	19012789	VA

General Provider Information

NPI Number	:	1811519119
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KELLY JO MARTINDALE LMT

Provider Business Mailing Address
First Line	:	3205 COURTLAND RD NW
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24012-7722
Country	:	US
Telephone Number	:	540-797-2392
Fax Number	:

Provider Business Practice Location Address
First Line	:	3140 CHAPARRAL DR # C-109
Second Line	:
City	:	ROANOKE
State	:	VA
Zip	:	24018-4355
Country	:	US
Telephone Number	:	540-525-9502
Fax Number	:

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

Provider Enumeration Date	:	05/11/2020
Last Update Date	:	05/11/2020

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