MEDICARE: DOUGLAS HAGY 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	225100000X	Physical Therapist	PT36568	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W15428	OTHER	CA	GROUP MEDICARE ID

General Provider Information

NPI Number	:	1063426914
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS HAGY PT

Provider Business Mailing Address
First Line	:	9100 S SEPULVEDA BLVD
Second Line	:	SUITE 116
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4814
Country	:	US
Telephone Number	:	310-649-6470
Fax Number	:	310-649-6471

Provider Business Practice Location Address
First Line	:	9100 S SEPULVEDA BLVD
Second Line	:	SUITE 116
City	:	LOS ANGELES
State	:	CA
Zip	:	90045-4814
Country	:	US
Telephone Number	:	310-649-6470
Fax Number	:	310-649-6471

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

Provider Enumeration Date	:	07/28/2006
Last Update Date	:	09/23/2015

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Directions to “ DOUGLAS HAGY PT” Practice Location

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