MEDICARE: DR. ZACHARY DAVID PEVNICK DPT

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	36828	CA
2	2251S0007X	Sports Physical Therapist	36828	CA
3	2251X0800X	Orthopedic Physical Therapist	36828	CA
4	261QP2000X	Physical Therapy Clinic/Center	36828	CA
5	2251G0304X	Geriatric Physical Therapist	36828	CA

General Provider Information

NPI Number	:	1578879516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ZACHARY DAVID PEVNICK DPT

Provider Business Mailing Address
First Line	:	12655 W JEFFERSON BLVD FL 4
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-7008
Country	:	US
Telephone Number	:	310-907-9215
Fax Number	:	310-953-3281

Provider Business Practice Location Address
First Line	:	12655 W JEFFERSON BLVD FL 4
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90066-7008
Country	:	US
Telephone Number	:	310-907-9215
Fax Number	:	310-953-3281

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

Provider Enumeration Date	:	08/27/2010
Last Update Date	:	07/10/2020

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