MEDICARE: NANCY LEE REDGATE PT

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	PT11278	CA

General Provider Information

NPI Number	:	1194851626
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY LEE REDGATE PT

Provider Business Mailing Address
First Line	:	PO BOX 4501
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91359-1501
Country	:	US
Telephone Number	:	805-469-4561
Fax Number	:

Provider Business Practice Location Address
First Line	:	1690 BLACKWALL DR
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93063-3208
Country	:	US
Telephone Number	:	805-469-4561
Fax Number	:

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	07/08/2007

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