MEDICARE: CLINICA PEDIATRICA DE TEREPIA, 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	2251P0200X	Pediatric Physical Therapist	611	PR

General Provider Information

NPI Number	:	1760779318
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLINICA PEDIATRICA DE TEREPIA, INC.

Provider Business Mailing Address
First Line	:	URB. LA RIVIERA SE 54
Second Line	:	1283
City	:	SAN JUAN
State	:	PR
Zip	:	00921
Country	:	US
Telephone Number	:	787-783-6290
Fax Number	:	787-782-0670

Provider Business Practice Location Address
First Line	:	URB. LA RIVIERA S.E. 54
Second Line	:	1283
City	:	SAN JUAN
State	:	PR
Zip	:	00921-3144
Country	:	US
Telephone Number	:	787-783-6290
Fax Number	:	787-782-0670

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. CARMEN TERESA MEDINA
Credential	:	DPT, MPT, NDTC
Telephone Number	:	787-783-6290

Provider Enumeration Date	:	07/05/2011
Last Update Date	:	07/05/2011

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