MEDICARE: WATER AND SPORTS PHYSICAL THERAPY

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	208100000X	Physical Medicine & Rehabilitation Physician	PT40754	CA

General Provider Information

NPI Number	:	1588085625
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WATER AND SPORTS PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	3639 MIDWAY DR
Second Line	:	B286
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-5254
Country	:	US
Telephone Number	:	858-488-3597
Fax Number	:	858-724-1747

Provider Business Practice Location Address
First Line	:	3639 MIDWAY DR
Second Line	:	B286
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-5254
Country	:	US
Telephone Number	:	858-488-3597
Fax Number	:	858-724-1747

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	SOPHIA HAMILTON
Credential	:
Telephone Number	:	858-726-2624

Provider Enumeration Date	:	12/16/2013
Last Update Date	:	12/16/2013

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Directions to “WATER AND SPORTS PHYSICAL THERAPY ” Practice Location

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