MEDICARE: NATALIE BLANCO MIRSKY

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	261QP2000X	Physical Therapy Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7458842	OTHER	CA	AETNA

General Provider Information

NPI Number	:	1487786133
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NATALIE BLANCO MIRSKY

Provider Business Mailing Address
First Line	:	1831 WILSHIRE BLVD STE E
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5779
Country	:	US
Telephone Number	:	310-453-1221
Fax Number	:	310-829-5319

Provider Business Practice Location Address
First Line	:	1831 WILSHIRE BLVD STE E
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90403-5779
Country	:	US
Telephone Number	:	310-453-1221
Fax Number	:	310-829-5319

Authorized Official
Title or Position	:	FOUNDER MANAGING DIRECTOR
Name	:	MRS. NATALIE BLANCO MIRSKY
Credential	:
Telephone Number	:	310-270-7549

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	06/27/2008

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Directions to “NATALIE BLANCO MIRSKY ” Practice Location

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