MEDICARE: MRS. DIANE SHEAD 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	PT21771	CA

General Provider Information

NPI Number	:	1811398126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DIANE SHEAD PT

Provider Business Mailing Address
First Line	:	1421 N WANDA RD
Second Line	:	SUITE 110
City	:	ORANGE
State	:	CA
Zip	:	92867-5343
Country	:	US
Telephone Number	:	714-771-7047
Fax Number	:	714-771-7051

Provider Business Practice Location Address
First Line	:	1421 N WANDA RD
Second Line	:	SUITE 110
City	:	ORANGE
State	:	CA
Zip	:	92867-5343
Country	:	US
Telephone Number	:	714-771-7047
Fax Number	:	714-771-7051

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

Provider Enumeration Date	:	09/06/2014
Last Update Date	:	09/06/2014

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