MEDICARE: MR. STEWART SUTUT TRITASAVIT M.P.T.

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	:	1336240514
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEWART SUTUT TRITASAVIT M.P.T.

Provider Business Mailing Address
First Line	:	11301 WILSHIRE BLVD
Second Line	:	117
City	:	LOS ANGELES
State	:	CA
Zip	:	90073-1003
Country	:	US
Telephone Number	:	310-478-3711
Fax Number	:

Provider Business Practice Location Address
First Line	:	11301 WILSHIRE BLVD
Second Line	:	BLDG.500 RM.1454
City	:	LOS ANGELES
State	:	CA
Zip	:	90073-1003
Country	:	US
Telephone Number	:	310-478-3711
Fax Number	:

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/16/2007

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