MEDICARE: SANDRA J WISE 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	6769	NM

General Provider Information

NPI Number	:	1881997740
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SANDRA J WISE LMT

Provider Business Mailing Address
First Line	:	6500 HOOCHANEETSA BLVD
Second Line	:
City	:	COCHITI LAKE
State	:	NM
Zip	:	87083-6030
Country	:	US
Telephone Number	:	505-465-0241
Fax Number	:

Provider Business Practice Location Address
First Line	:	6500 HOOCHANEETSA BLVD
Second Line	:
City	:	COCHITI LAKE
State	:	NM
Zip	:	87083-6030
Country	:	US
Telephone Number	:	505-465-0241
Fax Number	:

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

Provider Enumeration Date	:	12/15/2010
Last Update Date	:	12/15/2010

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