MEDICARE: MAILA TIBBERTS 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	031126-1	NY
2	225100000X	Physical Therapist	PT 36737	CA

General Provider Information

NPI Number	:	1477887321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAILA TIBBERTS P.T.

Provider Business Mailing Address
First Line	:	4640 CANEEL BAY CT
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92057-4223
Country	:	US
Telephone Number	:	109-566-1053
Fax Number	:

Provider Business Practice Location Address
First Line	:	12113 SANTA MONICA BLVD
Second Line	:	SUITE 203
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-2581
Country	:	US
Telephone Number	:	310-309-3721
Fax Number	:

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

Provider Enumeration Date	:	09/24/2009
Last Update Date	:	11/17/2020

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Directions to “ MAILA TIBBERTS P.T.” Practice Location

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