MEDICARE: WELLCARE PHYSICAL THERAPY 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	15084	CA

General Provider Information

NPI Number	:	1104002518
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLCARE PHYSICAL THERAPY INC.

Provider Business Mailing Address
First Line	:	4157 EAGLE ROCK BLVD
Second Line	:	SUITE 7
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-4492
Country	:	US
Telephone Number	:	323-982-1566
Fax Number	:	323-982-1680

Provider Business Practice Location Address
First Line	:	4157 EAGLE ROCK BLVD
Second Line	:	SUITE 7
City	:	LOS ANGELES
State	:	CA
Zip	:	90065-4492
Country	:	US
Telephone Number	:	323-982-1566
Fax Number	:	323-982-1680

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MARC JIMENEZ GOMEZ III
Credential	:
Telephone Number	:	323-982-1566

Provider Enumeration Date	:	01/15/2008
Last Update Date	:	04/16/2008

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