MEDICARE: CHRISTOPHER P DEROSA RPT

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	PT25505	CA

General Provider Information

NPI Number	:	1003056797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER P DEROSA RPT

Provider Business Mailing Address
First Line	:	325 MAIN ST
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3814
Country	:	US
Telephone Number	:	310-648-3167
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 MAIN ST
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3814
Country	:	US
Telephone Number	:	310-648-3167
Fax Number	:

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

Provider Enumeration Date	:	02/20/2009
Last Update Date	:	12/31/2013

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