MEDICARE: EVONDA TIMBERS CMT

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	174400000X	Specialist	26BT00045400	NJ

General Provider Information

NPI Number	:	1871762310
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVONDA TIMBERS CMT

Provider Business Mailing Address
First Line	:	11 MANYMIND AVE
Second Line	:
City	:	ATLANTIC HIGHLANDS
State	:	NJ
Zip	:	07716-1622
Country	:	US
Telephone Number	:	908-902-1579
Fax Number	:

Provider Business Practice Location Address
First Line	:	11 MANYMIND AVE
Second Line	:
City	:	ATLANTIC HIGHLANDS
State	:	NJ
Zip	:	07716-1622
Country	:	US
Telephone Number	:	908-902-1579
Fax Number	:

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

Provider Enumeration Date	:	02/28/2008
Last Update Date	:	02/28/2008

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