=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720175011
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTIAN LAMA MEDINA PHYSICAL THERAPY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 09/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18300 GRIDLEY RD STE 301
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90701-5401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-924-0934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18300 GRIDLEY RD STE 301
-----------------------------------------------------
City | ARTESIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90701-5401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-924-0934
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHRISTIAN LAMA MEDINA
-----------------------------------------------------
Credential | RPT
-----------------------------------------------------
Telephone | 562-924-0934
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT29198
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------