MEDICARE: LADERA RANCH 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	225100000X	Physical Therapist		CA

General Provider Information

NPI Number	:	1255654398
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LADERA RANCH PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	777 CORPORATE DR
Second Line	:	SUITE 160
City	:	LADERA RANCH
State	:	CA
Zip	:	92694-2135
Country	:	US
Telephone Number	:	949-472-2242
Fax Number	:	949-472-4501

Provider Business Practice Location Address
First Line	:	777 CORPORATE DR
Second Line	:	SUITE 160
City	:	LADERA RANCH
State	:	CA
Zip	:	92694-2135
Country	:	US
Telephone Number	:	949-472-2242
Fax Number	:	949-472-4501

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MRS. KAREN HERZ
Credential	:
Telephone Number	:	949-754-1344

Provider Enumeration Date	:	03/03/2010
Last Update Date	:	02/24/2015

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