MEDICARE: CHRISTINA MARIE BANUELOS DPT

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	PT29685	CA
2	225100000X	Physical Therapist	PTL.0015246	CO

General Provider Information

NPI Number	:	1548773500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINA MARIE BANUELOS DPT

Provider Business Mailing Address
First Line	:	10790 RANCHO BERNARDO RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92127-5705
Country	:	US
Telephone Number	:	858-487-1800
Fax Number	:

Provider Business Practice Location Address
First Line	:	6160 TUTT BLVD STE 240
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-3502
Country	:	US
Telephone Number	:	719-596-0880
Fax Number	:	719-596-0899

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

Provider Enumeration Date	:	11/13/2017
Last Update Date	:	04/22/2021

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