MEDICARE: GARY PEVNICK 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	00394	MO

General Provider Information

NPI Number	:	1245260769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY PEVNICK PT

Provider Business Mailing Address
First Line	:	30 QUARTERDECK ST APT 3
Second Line	:
City	:	MARINA DEL REY
State	:	CA
Zip	:	90292-6700
Country	:	US
Telephone Number	:	314-570-5153
Fax Number	:

Provider Business Practice Location Address
First Line	:	12655 W JEFFERSON BLVD FL 4
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-7008
Country	:	US
Telephone Number	:	310-907-9215
Fax Number	:	310-953-3281

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

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	07/29/2020

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Directions to “ GARY PEVNICK PT” Practice Location

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