MEDICARE: BLUE WATER PHYSICAL THERAPY

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	PT30454	CA

General Provider Information

NPI Number	:	1942435045
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUE WATER PHYSICAL THERAPY

Provider Business Mailing Address
First Line	:	2063 SAN ELIJO AVE
Second Line	:
City	:	CARDIFF
State	:	CA
Zip	:	92007-1726
Country	:	US
Telephone Number	:	714-623-2035
Fax Number	:

Provider Business Practice Location Address
First Line	:	2063 SAN ELIJO AVE
Second Line	:
City	:	CARDIFF
State	:	CA
Zip	:	92007-1726
Country	:	US
Telephone Number	:	714-623-2035
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ERIN RENEE MALECHA
Credential	:	MPT
Telephone Number	:	714-623-2035

Provider Enumeration Date	:	05/19/2009
Last Update Date	:	01/28/2015

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Directions to “BLUE WATER PHYSICAL THERAPY ” Practice Location

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