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NPI Code Detail

MEDICARE: JUDD DONNELLY PT

MEDICARE: JUDD DONNELLY PT
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
1225100000XPhysical Therapist

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1PT38010OTHERCAPT LICENSE
2FF352ZOTHERMCR PTAN

General Provider Information

NPI Number : 1558657387
Entity Type Code : Individual
Provider Name (Legal Business Name) : JUDD DONNELLY PT
Provider Business Mailing Address
First Line : 435 N BEDFORD DR STE 102
Second Line :
City : BEVERLY HILLS
State : CA
Zip : 90210-4319
Country : US
Telephone Number : 310-385-9064
Fax Number :
Provider Business Practice Location Address
First Line : 435 N BEDFORD DR STE 102
Second Line :
City : BEVERLY HILLS
State : CA
Zip : 90210-4319
Country : US
Telephone Number : 310-385-9064
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/20/2011
Last Update Date : 11/21/2016

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Directions to “ JUDD DONNELLY PT” Practice Location

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