Healthcare Provider Details

I. General information

NPI: 1619149531
Provider Name (Legal Business Name): WINDSOR SHANE BUZZA MPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 03/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 LILAC LN
CARMEL VALLEY CA
93924-9624
US

IV. Provider business mailing address

25 LILAC LN
CARMEL VALLEY CA
93924-9624
US

V. Phone/Fax

Practice location:
  • Phone: 831-659-4199
  • Fax: 831-659-4199
Mailing address:
  • Phone: 831-659-4199
  • Fax: 831-659-4199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT21232
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: