MEDICARE: NICOLE INDART

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	2251X0800X	Orthopedic Physical Therapist	PT24274	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT24274	OTHER	CA	PT LICENSE

General Provider Information

NPI Number	:	1154787224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE INDART

Provider Business Mailing Address
First Line	:	3717 MT DIABLO BLVD
Second Line	:	SUITE 100
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-3588
Country	:	US
Telephone Number	:	925-284-5300
Fax Number	:	925-284-5381

Provider Business Practice Location Address
First Line	:	3717 MT DIABLO BLVD
Second Line	:	SUITE 100
City	:	LAFAYETTE
State	:	CA
Zip	:	94549-3588
Country	:	US
Telephone Number	:	925-284-5300
Fax Number	:	925-284-5381

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

Provider Enumeration Date	:	01/05/2016
Last Update Date	:	02/11/2025

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Practice Location Address:

3717 MT DIABLO BLVD , SUITE100
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94549-3588

Practice Phone: 925-284-5300
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1275624405 — DAVID HATAE PT
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3717 MT DIABLO BLVD , SUITE 100
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1639517907 — EDWARD CRAIG KLASS PT
Practice Location Address:

3717 MT DIABLO BLVD , SUITE 100
LAFAYETTE, CA
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Practice Phone: 925-284-5300
Practice Fax: 925-284-5381

1124633060 — ELISE PELLETT PT, DPT
Practice Location Address:

3717 MT DIABLO BLVD
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Practice Fax:

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Practice Location Address:

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1225037625 — STEVEN JOSEPH MARCINKOWSKI
Practice Location Address:

3675 MT DIABLO BLVD STE 110
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Directions to “ NICOLE INDART ” Practice Location

Language	Start Address	Practice Location

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