MEDICARE: GLENN MCCLEISTER LMT, MMT

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	NVMT.1007	NV

General Provider Information

NPI Number	:	1962840439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLENN MCCLEISTER LMT, MMT

Provider Business Mailing Address
First Line	:	4471 ELK POINT CIR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89147-6206
Country	:	US
Telephone Number	:	702-371-3702
Fax Number	:	702-247-9744

Provider Business Practice Location Address
First Line	:	2595 S CIMARRON RD
Second Line	:	STE 206
City	:	LAS VEGAS
State	:	NV
Zip	:	89117-7613
Country	:	US
Telephone Number	:	702-371-3702
Fax Number	:	702-247-9744

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

Provider Enumeration Date	:	06/06/2013
Last Update Date	:	06/06/2013

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