MEDICARE: PHYSICAL EDGE, INC.

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	6526	CA
2	225100000X	Physical Therapist	30188	CA
3	225100000X	Physical Therapist	32377	CA
4	225100000X	Physical Therapist	27732	CA
5	225XH1200X	Hand Occupational Therapist	1528	CA
6	225100000X	Physical Therapist	22276	CA

General Provider Information

NPI Number	:	1689606469
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYSICAL EDGE, INC.

Provider Business Mailing Address
First Line	:	1970 LAKE BLVD STE 4
Second Line	:
City	:	DAVIS
State	:	CA
Zip	:	95616-5663
Country	:	US
Telephone Number	:	530-753-9011
Fax Number	:	530-753-9021

Provider Business Practice Location Address
First Line	:	1970 LAKE BLVD STE 4
Second Line	:
City	:	DAVIS
State	:	CA
Zip	:	95616-5663
Country	:	US
Telephone Number	:	530-753-9011
Fax Number	:	530-753-9021

Authorized Official
Title or Position	:	OWNER
Name	:	MR. MATHEW MOORE
Credential	:	MPT
Telephone Number	:	530-753-9011

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	03/13/2009

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Directions to “PHYSICAL EDGE, INC. ” Practice Location

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