MEDICARE: SHAFA PHYSICAL THERAPY, SPORT INJURY AND REHABILITATION CENTER, INC.

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	225100000X	Physical Therapist	PT 34634	CA

General Provider Information

NPI Number	:	1033438379
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHAFA PHYSICAL THERAPY, SPORT INJURY AND REHABILITATION CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 6597
Second Line	:
City	:	BEVERLY HILLS
State	:	CA
Zip	:	90212-6597
Country	:	US
Telephone Number	:	310-777-7594
Fax Number	:

Provider Business Practice Location Address
First Line	:	11819 WILSHIRE BLVD
Second Line	:	SUITE # 205
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-6619
Country	:	US
Telephone Number	:	310-777-7594
Fax Number	:

Authorized Official
Title or Position	:	PT
Name	:	DORIS SHADROOZ
Credential	:
Telephone Number	:	310-552-9575

Provider Enumeration Date	:	05/26/2010
Last Update Date	:	05/26/2010

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