MEDICARE: MARIO M MANCUSI RPT

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	PT 13286	CA

General Provider Information

NPI Number	:	1306013636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIO M MANCUSI RPT

Provider Business Mailing Address
First Line	:	902 SYCAMORE AVE
Second Line	:	SUITE 201
City	:	VISTA
State	:	CA
Zip	:	92081-7879
Country	:	US
Telephone Number	:	760-940-0500
Fax Number	:	760-940-0570

Provider Business Practice Location Address
First Line	:	902 SYCAMORE AVE
Second Line	:	SUITE 201
City	:	VISTA
State	:	CA
Zip	:	92081-7879
Country	:	US
Telephone Number	:	760-940-0500
Fax Number	:	760-940-0570

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

Provider Enumeration Date	:	05/15/2008
Last Update Date	:	03/25/2009

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