MEDICARE: DR. JEDRICK B MAZION DPT

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	225100000X	Physical Therapist		SD

General Provider Information

NPI Number	:	1881119527
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEDRICK B MAZION DPT

Provider Business Mailing Address
First Line	:	5622 SHERIDAN LAKE ROAD
Second Line	:	SUITE 105
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8881
Country	:	US
Telephone Number	:	605-721-3307
Fax Number	:	605-721-3308

Provider Business Practice Location Address
First Line	:	5622 SHERIDAN LAKE RD STE 105
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-8881
Country	:	US
Telephone Number	:	602-721-3307
Fax Number	:	605-721-3308

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

Provider Enumeration Date	:	08/03/2017
Last Update Date	:	07/21/2022

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