=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164754875
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEN MICHAEL EVARDOME PTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/04/2010
-----------------------------------------------------
Last Update Date | 02/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34835 FAIRPORT WAY
-----------------------------------------------------
City | YUCAIPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92399-6817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-570-9573
-----------------------------------------------------
Fax | 909-570-9573
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 34835 FAIRPORT WAY
-----------------------------------------------------
City | YUCAIPA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92399-6817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-570-9573
-----------------------------------------------------
Fax | 909-570-9573
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | AT6602
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------