MEDICARE: KRISTINA MARIE LORENZO VILLARUZ PTA

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	225200000X	Physical Therapy Assistant	49468	CA

General Provider Information

NPI Number	:	1982186029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTINA MARIE LORENZO VILLARUZ PTA

Provider Business Mailing Address
First Line	:	17435 SARITA AVE
Second Line	:
City	:	CANYON COUNTRY
State	:	CA
Zip	:	91387-3590
Country	:	US
Telephone Number	:	661-993-0090
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 E MAPLE AVE
Second Line	:
City	:	EL SEGUNDO
State	:	CA
Zip	:	90245-6507
Country	:	US
Telephone Number	:	310-316-6190
Fax Number	:

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

Provider Enumeration Date	:	09/05/2018
Last Update Date	:	09/05/2018

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