MEDICARE: CONTRA COSTA PHYSICAL THERAPY

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	261QP2000X	Physical Therapy Clinic/Center	PT11158	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT11158	OTHER	CA	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1952518714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONTRA COSTA PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	3065 RICHMOND PKWY STE 105
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94806-5718
Country	:	US
Telephone Number	:	510-758-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	3065 RICHMOND PKWY STE 105
Second Line	:
City	:	RICHMOND
State	:	CA
Zip	:	94806-5718
Country	:	US
Telephone Number	:	510-758-1111
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. ANDRE CYRIL MALIN
Credential	:	P.T.
Telephone Number	:	510-758-1111

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	07/16/2008

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Directions to “CONTRA COSTA PHYSICAL THERAPY ” Practice Location

Language	Start Address	Practice Location

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