MEDICARE: DACOSTA ALONZO COLLYMORE RPT

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	20709	CA

General Provider Information

NPI Number	:	1568497659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DACOSTA ALONZO COLLYMORE RPT

Provider Business Mailing Address
First Line	:	5000 OVERLAND AVE STE 4
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-4995
Country	:	US
Telephone Number	:	310-836-7650
Fax Number	:	310-836-7651

Provider Business Practice Location Address
First Line	:	5000 OVERLAND AVE STE 4
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-4995
Country	:	US
Telephone Number	:	310-836-7650
Fax Number	:	310-836-7651

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

Provider Enumeration Date	:	07/11/2006
Last Update Date	:	07/09/2007

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