MEDICARE: STACEY EIDLEBACH CASTER 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	MT.0017786	CO

General Provider Information

NPI Number	:	1841657210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY EIDLEBACH CASTER LMT

Provider Business Mailing Address
First Line	:	5 W LAS ANIMAS ST
Second Line	:	APT 3
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-4164
Country	:	US
Telephone Number	:	682-472-5054
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 W LAS ANIMAS ST
Second Line	:	APT 3
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80903-4164
Country	:	US
Telephone Number	:	682-472-5054
Fax Number	:

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

Provider Enumeration Date	:	01/15/2016
Last Update Date	:	01/15/2016

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