MEDICARE: MARK BECKETT

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	PT7709	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT7709	OTHER	FL	LICENSE #

General Provider Information

NPI Number	:	1922118629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK BECKETT

Provider Business Mailing Address
First Line	:	8444 TIBET BUTLER DR
Second Line	:
City	:	WINDERMERE
State	:	FL
Zip	:	34786-5304
Country	:	US
Telephone Number	:	919-303-1631
Fax Number	:

Provider Business Practice Location Address
First Line	:	1177 BLACKWOOD AVE
Second Line	:
City	:	OCOEE
State	:	FL
Zip	:	34761-4518
Country	:	US
Telephone Number	:	407-292-0073
Fax Number	:

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	07/08/2007

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