MEDICARE: CRYSTAL DRAGON PTA

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	225200000X	Physical Therapy Assistant	51025	CA

General Provider Information

NPI Number	:	1043971799
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CRYSTAL DRAGON PTA

Provider Business Mailing Address
First Line	:	3165 SACRAMENTO ST
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-5530
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3165 SACRAMENTO ST
Second Line	:
City	:	PLACERVILLE
State	:	CA
Zip	:	95667-5530
Country	:	US
Telephone Number	:	707-365-8864
Fax Number	:

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

Provider Enumeration Date	:	01/05/2022
Last Update Date	:	01/05/2022

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Directions to “ CRYSTAL DRAGON PTA” Practice Location

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