MEDICARE: MS. PEGGY RENE RISCH RPT

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	PT9136	CA

General Provider Information

NPI Number	:	1922248590
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. PEGGY RENE RISCH RPT

Provider Business Mailing Address
First Line	:	PO BOX 882
Second Line	:
City	:	MOUNT SHASTA
State	:	CA
Zip	:	96067-2761
Country	:	US
Telephone Number	:	530-261-1344
Fax Number	:

Provider Business Practice Location Address
First Line	:	206 ROELOFS CT
Second Line	:	SUITE C
City	:	MOUNT SHASTA
State	:	CA
Zip	:	96067-2761
Country	:	US
Telephone Number	:	530-261-1344
Fax Number	:

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

Provider Enumeration Date	:	02/23/2009
Last Update Date	:	03/30/2009

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