MEDICARE: JOHNATHAN JAMES LAZNOVSKY 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	032030	NY

General Provider Information

NPI Number	:	1891332300
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNATHAN JAMES LAZNOVSKY LMT

Provider Business Mailing Address
First Line	:	920 LINCOLN AVE UNIT 11
Second Line	:
City	:	HOLBROOK
State	:	NY
Zip	:	11741-2257
Country	:	US
Telephone Number	:	631-256-5184
Fax Number	:

Provider Business Practice Location Address
First Line	:	920 LINCOLN AVE UNIT 11
Second Line	:
City	:	HOLBROOK
State	:	NY
Zip	:	11741-2257
Country	:	US
Telephone Number	:	631-256-5184
Fax Number	:

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

Provider Enumeration Date	:	12/03/2019
Last Update Date	:	12/03/2019

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