MEDICARE: DARWIN LANCE FOGT MPT

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	PT26595	CA

General Provider Information

NPI Number	:	1295782894
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DARWIN LANCE FOGT MPT

Provider Business Mailing Address
First Line	:	322 CULVER BLVD
Second Line	:
City	:	PLAYA DEL REY
State	:	CA
Zip	:	90293-7784
Country	:	US
Telephone Number	:	310-915-6100
Fax Number	:	310-915-0100

Provider Business Practice Location Address
First Line	:	11825 MAJOR ST
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-6356
Country	:	US
Telephone Number	:	310-915-6100
Fax Number	:	310-915-0100

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

Provider Enumeration Date	:	05/28/2006
Last Update Date	:	11/30/2009

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