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NPI Code Detail

MEDICARE: MARY ELLEN (NMN) LAKE LMT, CNMT

MEDICARE: MARY ELLEN (NMN) LAKE LMT, CNMT
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
1225700000XMassage Therapist709188CO

General Provider Information

NPI Number : 1952513996
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY ELLEN (NMN) LAKE LMT, CNMT
Provider Business Mailing Address
First Line : 656 GLEN EYRIE CIR
Second Line :
City : COLORADO SPRINGS
State : CO
Zip : 80904-2139
Country : US
Telephone Number : 719-578-3012
Fax Number :
Provider Business Practice Location Address
First Line : 2020 W COLORADO AVE
Second Line : SUITE 101
City : COLORADO SPRINGS
State : CO
Zip : 80904-3882
Country : US
Telephone Number : 719-660-1686
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/03/2007
Last Update Date : 07/08/2007

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