MEDICARE: CARLSON PHYSICAL THERAPY, INC

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	2251G0304X	Geriatric Physical Therapist	19033	CA

General Provider Information

NPI Number	:	1255446860
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CARLSON PHYSICAL THERAPY, INC

Provider Business Mailing Address
First Line	:	8 YELLOWPINE LN
Second Line	:
City	:	TRABUCO CANYON
State	:	CA
Zip	:	92679-1420
Country	:	US
Telephone Number	:	949-713-7939
Fax Number	:

Provider Business Practice Location Address
First Line	:	8 YELLOWPINE LN
Second Line	:
City	:	TRABUCO CANYON
State	:	CA
Zip	:	92679-1420
Country	:	US
Telephone Number	:	949-713-7939
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. TIMOTHY JAMES CARLSON
Credential	:	PT
Telephone Number	:	949-713-7939

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	02/28/2013

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