MEDICARE: RICHARD EDSON SMITH L.M.T

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	MA0010916	FL

General Provider Information

NPI Number	:	1891994117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD EDSON SMITH L.M.T

Provider Business Mailing Address
First Line	:	241 PONCE DE LEON DR
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32176-7874
Country	:	US
Telephone Number	:	386-441-7126
Fax Number	:

Provider Business Practice Location Address
First Line	:	241 PONCE DE LEON DR
Second Line	:
City	:	ORMOND BEACH
State	:	FL
Zip	:	32176-7874
Country	:	US
Telephone Number	:	386-441-7126
Fax Number	:

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

Provider Enumeration Date	:	07/16/2007
Last Update Date	:	08/03/2007

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