MEDICARE: LISSETTE ARELI MACCARONE

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	AT8004	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AT8004	OTHER	CA	STATE PTA LIC

General Provider Information

NPI Number	:	1780800565
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISSETTE ARELI MACCARONE

Provider Business Mailing Address
First Line	:	22218 ROSCOE BLVD
Second Line	:
City	:	CANOGA PARK
State	:	CA
Zip	:	91304-3343
Country	:	US
Telephone Number	:	310-435-1540
Fax Number	:

Provider Business Practice Location Address
First Line	:	22218 ROSCOE BLVD
Second Line	:
City	:	CANOGA PARK
State	:	CA
Zip	:	91304-3343
Country	:	US
Telephone Number	:	310-435-1540
Fax Number	:

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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Directions to “ LISSETTE ARELI MACCARONE ” Practice Location

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