MEDICARE: MS. RUBY FAITH OVERTON PTA

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	225200000X	Physical Therapy Assistant	5494	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5494	OTHER	CA	PHYSICAL THERAPY BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1679864797
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. RUBY FAITH OVERTON PTA

Provider Business Mailing Address
First Line	:	2360 PASEO DE LAURA UNIT 61
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92056-3721
Country	:	US
Telephone Number	:	714-916-8870
Fax Number	:

Provider Business Practice Location Address
First Line	:	6250 EL CAMINO REAL
Second Line	:
City	:	CARLSBAD
State	:	CA
Zip	:	92009-1603
Country	:	US
Telephone Number	:	760-476-2900
Fax Number	:	760-940-4007

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

Provider Enumeration Date	:	04/23/2011
Last Update Date	:	04/23/2011

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Directions to “ MS. RUBY FAITH OVERTON PTA” Practice Location

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