MEDICARE: MINA PARK

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

General Provider Information

NPI Number	:	1285411405
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINA PARK

Provider Business Mailing Address
First Line	:	1495 VICTOR AVE STE A
Second Line	:
City	:	REDDING
State	:	CA
Zip	:	96003-4093
Country	:	US
Telephone Number	:	530-221-9952
Fax Number	:	530-221-9910

Provider Business Practice Location Address
First Line	:	844 BRIDGE ST STE C
Second Line	:
City	:	COLUSA
State	:	CA
Zip	:	95932-2867
Country	:	US
Telephone Number	:	530-458-7770
Fax Number	:	530-458-7735

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

Provider Enumeration Date	:	09/11/2023
Last Update Date	:	09/11/2023

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Directions to “ MINA PARK ” Practice Location

Language	Start Address	Practice Location

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