MEDICARE: MR. DATUS PURYEAR

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	225A00000X	Music Therapist

General Provider Information

NPI Number	:	1912357666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DATUS PURYEAR

Provider Business Mailing Address
First Line	:	6305 KENNEDY BLVD E APT A2
Second Line	:
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-4148
Country	:	US
Telephone Number	:	740-403-4567
Fax Number	:

Provider Business Practice Location Address
First Line	:	6305 KENNEDY BLVD E APT A2
Second Line	:
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-4148
Country	:	US
Telephone Number	:	740-403-4567
Fax Number	:

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

Provider Enumeration Date	:	06/14/2016
Last Update Date	:	06/14/2016

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