MEDICARE: CHRISTINE ELY M.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	174400000X	Specialist	PT18744	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT18744	OTHER	CA	LICENSE #

General Provider Information

NPI Number	:	1811965841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTINE ELY M.P.T.

Provider Business Mailing Address
First Line	:	785 MAIN ST
Second Line	:	SUITE A
City	:	HALF MOON BAY
State	:	CA
Zip	:	94019
Country	:	US
Telephone Number	:	650-712-8400
Fax Number	:	650-712-8600

Provider Business Practice Location Address
First Line	:	785 MAIN ST
Second Line	:
City	:	HALF MOON BAY
State	:	CA
Zip	:	94019-1992
Country	:	US
Telephone Number	:	650-712-8400
Fax Number	:

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

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	10/07/2008

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