MEDICARE: MISS PATRICIA LOUISE PENICK 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	174400000X	Specialist	PT 16717	CA

General Provider Information

NPI Number	:	1588874606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS PATRICIA LOUISE PENICK PT

Provider Business Mailing Address
First Line	:	3508 WISTERIA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-1150
Country	:	US
Telephone Number	:	619-223-0400
Fax Number	:	619-223-0400

Provider Business Practice Location Address
First Line	:	3508 WISTERIA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-1150
Country	:	US
Telephone Number	:	619-223-0400
Fax Number	:	619-223-0400

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

Provider Enumeration Date	:	05/24/2007
Last Update Date	:	07/08/2007

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