MEDICARE: MS. COLEEN KAY MAYO 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	PT6708	CA

General Provider Information

NPI Number	:	1114044062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. COLEEN KAY MAYO P.T.

Provider Business Mailing Address
First Line	:	9381 FIRESIDE DR
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92646-5903
Country	:	US
Telephone Number	:	714-963-7965
Fax Number	:

Provider Business Practice Location Address
First Line	:	17456 BEACH BLVD STE 102
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92647-5913
Country	:	US
Telephone Number	:	714-841-2688
Fax Number	:

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

Provider Enumeration Date	:	03/24/2007
Last Update Date	:	07/08/2007

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