MEDICARE: TROY DAVIS RPT

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT25036	OTHER	CA	PHYSICAL THERAPY LICENSE

General Provider Information

NPI Number	:	1760535314
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TROY DAVIS RPT

Provider Business Mailing Address
First Line	:	416 E WALNUT AVE
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-2438
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	325 MAIN ST
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-3814
Country	:	US
Telephone Number	:	310-648-3167
Fax Number	:

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

Provider Enumeration Date	:	01/18/2007
Last Update Date	:	05/23/2008

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Directions to “ TROY DAVIS RPT” Practice Location

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