MEDICARE: MADISON AVENUE PHYSICAL THERAPY

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	261QP2000X	Physical Therapy Clinic/Center	PT112750	CA

General Provider Information

NPI Number	:	1164747408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON AVENUE PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	5411 MADISON AVE
Second Line	:	SUITE 1
City	:	SACRAMENTO
State	:	CA
Zip	:	95841-3151
Country	:	US
Telephone Number	:	916-332-6050
Fax Number	:	916-332-6053

Provider Business Practice Location Address
First Line	:	5411 MADISON AVE
Second Line	:	SUITE 1
City	:	SACRAMENTO
State	:	CA
Zip	:	95841-3151
Country	:	US
Telephone Number	:	916-332-6050
Fax Number	:	916-332-6053

Authorized Official
Title or Position	:	OWNER/THERAPIST
Name	:	MR. MICHAEL RICHARD CROOKS
Credential	:	PT
Telephone Number	:	916-332-6050

Provider Enumeration Date	:	03/30/2010
Last Update Date	:	03/30/2010

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