MEDICARE: MR. BENJAMIN C ISIP RPT/L

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	PT16394	CA

General Provider Information

NPI Number	:	1568561579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BENJAMIN C ISIP RPT/L

Provider Business Mailing Address
First Line	:	12832 GARDEN GROVE BLVD.
Second Line	:	SUITE A
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-2002
Country	:	US
Telephone Number	:	714-534-1100
Fax Number	:	714-534-1140

Provider Business Practice Location Address
First Line	:	12832 GARDEN GROVE BLVD.
Second Line	:	SUITE A
City	:	GARDEN GROVE
State	:	CA
Zip	:	92843-2002
Country	:	US
Telephone Number	:	714-534-1100
Fax Number	:	714-534-1140

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	05/29/2009

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