MEDICARE: MITAS MOINA BALBIN MEDRANO

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	7029	AZ
2	225100000X	Physical Therapist	23719	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811977457
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MITAS MOINA BALBIN MEDRANO

Provider Business Mailing Address
First Line	:	20508 W DANIEL PL
Second Line	:
City	:	BUCKEYE
State	:	AZ
Zip	:	85396-3649
Country	:	US
Telephone Number	:	650-580-3503
Fax Number	:	623-776-2813

Provider Business Practice Location Address
First Line	:	20508 W DANIEL PL
Second Line	:
City	:	BUCKEYE
State	:	AZ
Zip	:	85396-3649
Country	:	US
Telephone Number	:	650-580-3503
Fax Number	:	623-776-2813

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

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	04/13/2017

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Directions to “ MITAS MOINA BALBIN MEDRANO ” Practice Location

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