MEDICARE: NISSA L CASUGA DPT

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	PT29088	CA

General Provider Information

NPI Number	:	1134125883
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NISSA L CASUGA DPT

Provider Business Mailing Address
First Line	:	6850 BROCKTON AVE
Second Line	:	STE 212
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3808
Country	:	US
Telephone Number	:	951-774-4611
Fax Number	:	951-276-3597

Provider Business Practice Location Address
First Line	:	6860 BROCKTON AVE
Second Line	:	STE 7
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3821
Country	:	US
Telephone Number	:	951-369-0860
Fax Number	:	951-774-4623

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	12/03/2021

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