MEDICARE: PREMIER SPORTS MEDICINE AND 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	25727	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AO096Z	OTHER	CA	PTAN

General Provider Information

NPI Number	:	1629238191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PREMIER SPORTS MEDICINE AND PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	PO BOX 3751
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95063-3751
Country	:	US
Telephone Number	:	831-457-1800
Fax Number	:	831-457-1802

Provider Business Practice Location Address
First Line	:	1003 RIVER ST
Second Line	:	SUITE C
City	:	SANTA CRUZ
State	:	CA
Zip	:	95060-1754
Country	:	US
Telephone Number	:	831-457-1800
Fax Number	:	831-457-1802

Authorized Official
Title or Position	:	OWNER
Name	:	ERIC INGRAM
Credential	:
Telephone Number	:	831-457-1800

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	02/09/2009

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Directions to “PREMIER SPORTS MEDICINE AND PHYSICAL THERAPY ” Practice Location

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