MEDICARE: RESTORATIVE THERAPY ASSOCIATES

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	30301	CA

General Provider Information

NPI Number	:	1023311073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RESTORATIVE THERAPY ASSOCIATES

Provider Business Mailing Address
First Line	:	20431 JAMES BAY CIR
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-8833
Country	:	US
Telephone Number	:	949-855-0100
Fax Number	:	949-855-0134

Provider Business Practice Location Address
First Line	:	20431 JAMES BAY CIR
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-8833
Country	:	US
Telephone Number	:	949-855-0100
Fax Number	:	949-855-0134

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DEREK DECICCO
Credential	:
Telephone Number	:	949-855-0100

Provider Enumeration Date	:	12/14/2010
Last Update Date	:	01/05/2015

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