MEDICARE: LOURDES BELLA LAREZA BOURDON PT

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	24819	CA

General Provider Information

NPI Number	:	1811092919
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LOURDES BELLA LAREZA BOURDON PT

Provider Business Mailing Address
First Line	:	851 FREMONT AVE
Second Line	:	SUITE 114
City	:	LOS ALTOS
State	:	CA
Zip	:	94024-5698
Country	:	US
Telephone Number	:	650-947-0121
Fax Number	:	650-947-0121

Provider Business Practice Location Address
First Line	:	851 FREMONT AVE
Second Line	:	SUITE 114
City	:	LOS ALTOS
State	:	CA
Zip	:	94024-5698
Country	:	US
Telephone Number	:	650-947-0121
Fax Number	:	650-947-0121

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

Provider Enumeration Date	:	09/13/2006
Last Update Date	:	07/08/2007

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