MEDICARE: JON FREDERICO DPT

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	PT40724	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CA112200	OTHER	CA	MEDICARE PTAN

General Provider Information

NPI Number	:	1821429358
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JON FREDERICO DPT

Provider Business Mailing Address
First Line	:	24630 WASHINGTON AVE
Second Line	:	SUITE 200
City	:	MURRIETA
State	:	CA
Zip	:	92562-6131
Country	:	US
Telephone Number	:	951-696-9353
Fax Number	:	951-973-7216

Provider Business Practice Location Address
First Line	:	6860 BROCKTON AVE
Second Line	:	SUITE 7
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-3821
Country	:	US
Telephone Number	:	951-534-0600
Fax Number	:	951-534-0605

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

Provider Enumeration Date	:	12/10/2013
Last Update Date	:	02/25/2014

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Directions to “ JON FREDERICO DPT” Practice Location

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