MEDICARE: MR. VINCE SECKER P.T.

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	225100000X	Physical Therapist	2524	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ0293620	OTHER	AZ	BLUE CROSS OF AZ

General Provider Information

NPI Number	:	1730142217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VINCE SECKER P.T.

Provider Business Mailing Address
First Line	:	2281 W 24TH ST
Second Line	:	STE 10
City	:	YUMA
State	:	AZ
Zip	:	85364-6154
Country	:	US
Telephone Number	:	928-344-1656
Fax Number	:	928-344-5072

Provider Business Practice Location Address
First Line	:	2281 W 24TH ST
Second Line	:	STE 10
City	:	YUMA
State	:	AZ
Zip	:	85364-6154
Country	:	US
Telephone Number	:	928-344-1656
Fax Number	:	928-344-5072

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

Provider Enumeration Date	:	04/07/2006
Last Update Date	:	07/31/2007

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