MEDICARE: GERARDO MACIAS

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 291812	CA

General Provider Information

NPI Number	:	1356895908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GERARDO MACIAS

Provider Business Mailing Address
First Line	:	488 S SAN VICENTE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4107
Country	:	US
Telephone Number	:	323-655-9055
Fax Number	:	323-655-9255

Provider Business Practice Location Address
First Line	:	488 S SAN VICENTE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-4107
Country	:	US
Telephone Number	:	323-655-9055
Fax Number	:	323-655-9255

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

Provider Enumeration Date	:	08/12/2016
Last Update Date	:	08/30/2016

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Directions to “ GERARDO MACIAS ” Practice Location

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