MEDICARE: DR. JIMMY CARTER THOMAS D.MIN.

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	106H00000X	Marriage & Family Therapist	MT 0454	FL

General Provider Information

NPI Number	:	1982810438
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JIMMY CARTER THOMAS D.MIN.

Provider Business Mailing Address
First Line	:	630 POPE AVE NW
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4665
Country	:	US
Telephone Number	:	863-293-1087
Fax Number	:	863-292-2083

Provider Business Practice Location Address
First Line	:	630 POPE AVE NW
Second Line	:
City	:	WINTER HAVEN
State	:	FL
Zip	:	33881-4665
Country	:	US
Telephone Number	:	863-293-1087
Fax Number	:	863-292-2083

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

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	07/08/2007

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