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NPI Code Detail

MEDICARE: MS. LISA RIEDLE PT

MEDICARE: MS. LISA RIEDLE 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
12251S0007XSports Physical TherapistPT17939CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1PT17939OTHERCAPT LICENSE

General Provider Information

NPI Number : 1619095007
Entity Type Code : Individual
Provider Name (Legal Business Name) : MS. LISA RIEDLE PT
Provider Business Mailing Address
First Line : 3351 EL CAMINO REAL
Second Line : SUITE 180
City : ATHERTON
State : CA
Zip : 94027-3811
Country : US
Telephone Number : 650-365-8350
Fax Number : 650-365-8353
Provider Business Practice Location Address
First Line : 3351 EL CAMINO REAL
Second Line : SUITE 180
City : ATHERTON
State : CA
Zip : 94027-3811
Country : US
Telephone Number : 650-365-8350
Fax Number : 650-365-8353
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/26/2007
Last Update Date : 07/08/2007

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