MEDICARE: AUGUST BENJAMIN PRIVRATSKY JR. PT, CP

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	224P00000X	Prosthetist
2	225100000X	Physical Therapist	1797	OK
3	225100000X	Physical Therapist	350182-2401	UT
4	225100000X	Physical Therapist	1079887	TX
5	225100000X	Physical Therapist	29431	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6147910001	OTHER	UT	MEDICARE PROSTHETIST, DME SUPPLIER

General Provider Information

NPI Number	:	1467589358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUGUST BENJAMIN PRIVRATSKY JR. PT, CP

Provider Business Mailing Address
First Line	:	828 S HAYWARD ST
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92804-3823
Country	:	US
Telephone Number	:	760-277-4034
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 NEWPORT CENTER DR STE 3
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-7505
Country	:	US
Telephone Number	:	760-277-4034
Fax Number	:	949-719-2600

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

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	12/10/2020

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