MEDICARE: MIKE JOHN MAYNARD 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	3934	CA

General Provider Information

NPI Number	:	1700901253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIKE JOHN MAYNARD PTA

Provider Business Mailing Address
First Line	:	32 POTOMAC
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92620-3254
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4655 RUFFNER ST
Second Line	:	STE. 270
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2275
Country	:	US
Telephone Number	:	800-787-6787
Fax Number	:

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

Provider Enumeration Date	:	03/20/2007
Last Update Date	:	07/08/2007

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