MEDICARE: DONALD W POWELL 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	MAS-2642	ID

General Provider Information

NPI Number	:	1881053916
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DONALD W POWELL LMT

Provider Business Mailing Address
First Line	:	549 W 1ST N
Second Line	:
City	:	SAINT ANTHONY
State	:	ID
Zip	:	83445-1303
Country	:	US
Telephone Number	:	208-351-0191
Fax Number	:

Provider Business Practice Location Address
First Line	:	13 N BRIDGE ST
Second Line	:
City	:	SAINT ANTHONY
State	:	ID
Zip	:	83445-2110
Country	:	US
Telephone Number	:	208-351-0191
Fax Number	:

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

Provider Enumeration Date	:	02/17/2016
Last Update Date	:	02/17/2016

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