MEDICARE: CHRISTOPHER GRAHAM 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	225100000X	Physical Therapist	PT23979	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W15428	OTHER	CA	MEDICARE GROUP ID NUMBER

General Provider Information

NPI Number	:	1740288794
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTOPHER GRAHAM PT

Provider Business Mailing Address
First Line	:	247 MARKET ST APT C
Second Line	:
City	:	VENICE
State	:	CA
Zip	:	90291-5317
Country	:	US
Telephone Number	:	424-252-2916
Fax Number	:	424-253-2916

Provider Business Practice Location Address
First Line	:	1 LMU DR
Second Line	:	ATHLETIC DEPARTMENT
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-2650
Country	:	US
Telephone Number	:	424-252-9816
Fax Number	:	424-253-2916

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	09/23/2015

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