MEDICARE: MR. ELADIO DIESTO FLORES PT

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	33673	CA

General Provider Information

NPI Number	:	1023202579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ELADIO DIESTO FLORES PT

Provider Business Mailing Address
First Line	:	8352 YORKSHIRE AVE
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-6769
Country	:	US
Telephone Number	:	562-303-6207
Fax Number	:

Provider Business Practice Location Address
First Line	:	2920 WESTMINSTER AVE
Second Line	:
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-5305
Country	:	US
Telephone Number	:	562-594-8600
Fax Number	:	562-594-4599

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

Provider Enumeration Date	:	08/28/2007
Last Update Date	:	08/28/2007

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