MEDICARE: MISS REBECA LYN GARVIN P.T.

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	PT32851	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	W14553	OTHER	CA	MEDICARE GROUP NUMBER

General Provider Information

NPI Number	:	1710077227
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS REBECA LYN GARVIN P.T.

Provider Business Mailing Address
First Line	:	PO BOX 349
Second Line	:
City	:	SAN PEDRO
State	:	CA
Zip	:	90733-0349
Country	:	US
Telephone Number	:	310-548-0104
Fax Number	:

Provider Business Practice Location Address
First Line	:	28924 S WESTERN AVE
Second Line	:	SUITE 101
City	:	RANCHO PALOS VERDES
State	:	CA
Zip	:	90275-0885
Country	:	US
Telephone Number	:	310-548-0104
Fax Number	:

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

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	10/09/2007

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