MEDICARE: LINCOLN CITY PHYSICAL THERAPY, LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1073654166
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LINCOLN CITY PHYSICAL THERAPY, LLC

Provider Business Mailing Address
First Line	:	3007 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367-5131
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3007 NE WEST DEVILS LAKE RD
Second Line	:
City	:	LINCOLN CITY
State	:	OR
Zip	:	97367-5131
Country	:	US
Telephone Number	:	541-994-6252
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	CHARITO A MINA
Credential	:
Telephone Number	:	541-994-6252

Provider Enumeration Date	:	02/09/2007
Last Update Date	:	03/05/2013

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