MEDICARE: BETH W. MANTIS LMT

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	225400000X	Rehabilitation Practitioner	18018	OR

General Provider Information

NPI Number	:	1992056857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH W. MANTIS LMT

Provider Business Mailing Address
First Line	:	29544 SE HEIPLE RD
Second Line	:
City	:	EAGLE CREEK
State	:	OR
Zip	:	97022-9664
Country	:	US
Telephone Number	:	503-887-6070
Fax Number	:	503-630-2860

Provider Business Practice Location Address
First Line	:	29544 SE HEIPLE RD
Second Line	:
City	:	EAGLE CREEK
State	:	OR
Zip	:	97022-9664
Country	:	US
Telephone Number	:	503-887-6070
Fax Number	:	503-630-2860

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

Provider Enumeration Date	:	10/01/2012
Last Update Date	:	10/01/2012

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