MEDICARE: MR. MIRKO VUKSIC MPT, OCS, CSCS

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	2251X0800X	Orthopedic Physical Therapist	PT 27241	CA

General Provider Information

NPI Number	:	1922107614
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MIRKO VUKSIC MPT, OCS, CSCS

Provider Business Mailing Address
First Line	:	32261 CAMINO CAPISTRANO
Second Line	:	D101
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3746
Country	:	US
Telephone Number	:	949-429-2155
Fax Number	:	949-429-2151

Provider Business Practice Location Address
First Line	:	32261 CAMINO CAPISTRANO
Second Line	:	D101
City	:	SAN JUAN CAPISTRANO
State	:	CA
Zip	:	92675-3746
Country	:	US
Telephone Number	:	949-429-2155
Fax Number	:	949-429-2151

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	10/04/2013

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