MEDICARE: MS. MARIA D WICKHAM 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	17945	CA

General Provider Information

NPI Number	:	1578780714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARIA D WICKHAM RPT

Provider Business Mailing Address
First Line	:	2588 HYLER AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90041-2949
Country	:	US
Telephone Number	:	323-257-5736
Fax Number	:

Provider Business Practice Location Address
First Line	:	3699 WILSHIRE BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90010-2719
Country	:	US
Telephone Number	:	323-783-7499
Fax Number	:

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

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	07/08/2007

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