MEDICARE: AGNES SAMU REFY RPT

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	174400000X	Specialist	PT14384	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT14384	OTHER	CA	PHYSICAL THERAPY BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1093975872
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AGNES SAMU REFY RPT

Provider Business Mailing Address
First Line	:	1665 BLOSSOM HILL RD
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-6342
Country	:	US
Telephone Number	:	408-265-2560
Fax Number	:	408-265-6822

Provider Business Practice Location Address
First Line	:	1665 BLOSSOM HILL RD
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-6342
Country	:	US
Telephone Number	:	408-265-2560
Fax Number	:	408-265-6822

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

Provider Enumeration Date	:	06/14/2008
Last Update Date	:	06/14/2008

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