MEDICARE: MR. RYAN DEWITT 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	225100000X	Physical Therapist	PT 30137	CA

General Provider Information

NPI Number	:	1922105253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RYAN DEWITT P.T.

Provider Business Mailing Address
First Line	:	4125 PORTOLA DR
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95062-4525
Country	:	US
Telephone Number	:	831-475-2565
Fax Number	:	831-475-2572

Provider Business Practice Location Address
First Line	:	4125 PORTOLA DR
Second Line	:
City	:	SANTA CRUZ
State	:	CA
Zip	:	95062-4525
Country	:	US
Telephone Number	:	831-475-2565
Fax Number	:	831-475-2572

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	03/07/2011

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