MEDICARE: MARIA IMELDA AMIGLEO TE PT

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	PT33112	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT33112	OTHER	CA	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1174612204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA IMELDA AMIGLEO TE PT

Provider Business Mailing Address
First Line	:	4041 VIA MARISOL AVE.
Second Line	:	UNIT 305
City	:	LOS ANGELES
State	:	CA
Zip	:	90042
Country	:	US
Telephone Number	:	323-683-0445
Fax Number	:

Provider Business Practice Location Address
First Line	:	18391 COLIMA RD
Second Line	:	UNIT 205
City	:	ROWLAND HEIGHTS
State	:	CA
Zip	:	91748-2730
Country	:	US
Telephone Number	:	626-964-3326
Fax Number	:	626-964-3346

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

Provider Enumeration Date	:	10/12/2006
Last Update Date	:	07/08/2007

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