MEDICARE: PROFESSIONAL PHYSICAL THERAPY

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	261QP2000X	Physical Therapy Clinic/Center	PT18659	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OPT186590	OTHER	CA	MEDICARE PROVIDER #

General Provider Information

NPI Number	:	1578847257
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	2138 MARGUERITE ST
Second Line	:
City	:	DOS PALOS
State	:	CA
Zip	:	93620-2351
Country	:	US
Telephone Number	:	209-392-8830
Fax Number	:	209-392-8830

Provider Business Practice Location Address
First Line	:	2138 MARGUERITE ST
Second Line	:
City	:	DOS PALOS
State	:	CA
Zip	:	93620-2351
Country	:	US
Telephone Number	:	209-392-8830
Fax Number	:	209-392-8830

Authorized Official
Title or Position	:	P.T. / OWNER
Name	:	JULIE S REYNOLDS
Credential	:	P.T.
Telephone Number	:	209-392-8830

Provider Enumeration Date	:	09/29/2011
Last Update Date	:	09/29/2011

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Directions to “PROFESSIONAL PHYSICAL THERAPY ” Practice Location

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