MEDICARE: MRS. DAGNIJA M PETERSON P.T.

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 6253	CA

General Provider Information

NPI Number	:	1104824499
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DAGNIJA M PETERSON P.T.

Provider Business Mailing Address
First Line	:	4283 PIEDMONT AVE
Second Line	:	SUITE E5
City	:	OAKLAND
State	:	CA
Zip	:	94611-4758
Country	:	US
Telephone Number	:	510-923-0848
Fax Number	:	510-654-1406

Provider Business Practice Location Address
First Line	:	4283 PIEDMONT AVE
Second Line	:	SUITE E5
City	:	OAKLAND
State	:	CA
Zip	:	94611-4758
Country	:	US
Telephone Number	:	510-923-0848
Fax Number	:	510-654-1406

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

Provider Enumeration Date	:	07/11/2005
Last Update Date	:	08/13/2010

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