MEDICARE: PHYSIOSPORT: PERFORMANCE AND 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1265029128
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSIOSPORT: PERFORMANCE AND PHYSICAL THERAPY INC.

Provider Business Mailing Address
First Line	:	4929 FRANCO AVE
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95212-1909
Country	:	US
Telephone Number	:	209-481-7336
Fax Number	:

Provider Business Practice Location Address
First Line	:	4929 FRANCO AVE
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95212-1909
Country	:	US
Telephone Number	:	209-481-7336
Fax Number	:

Authorized Official
Title or Position	:	CEO/PRESIDENT
Name	:	MAHMOUD DAHER
Credential	:	DPT
Telephone Number	:	209-481-7336

Provider Enumeration Date	:	12/27/2020
Last Update Date	:	12/28/2020

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