MEDICARE: LARS E HOLMBERG PTA

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	225200000X	Physical Therapy Assistant

General Provider Information

NPI Number	:	1699236075
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LARS E HOLMBERG PTA

Provider Business Mailing Address
First Line	:	1505 MERIDIAN AVE STE A
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5353
Country	:	US
Telephone Number	:	408-264-6643
Fax Number	:

Provider Business Practice Location Address
First Line	:	1505 MERIDIAN AVE STE A
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5353
Country	:	US
Telephone Number	:	408-264-6643
Fax Number	:

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

Provider Enumeration Date	:	03/27/2019
Last Update Date	:	03/27/2019

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