Eric Blair

 
 From dcatalyst16 
 18443858095 
 8/29/2022 10:58:59 PDT 
 Page 13 of 17 
 Dr Adam Prince MD 
 Today's Date: 07/02/21
 RehabOne Medical Group, Inc. 
 All Clinics' US Mail Address: 13980 Blossom Hill Road, STE B Los Gatos, CA 92432 
 Industrial Injury Info: 
 DATE OF BIRTH: 
 02/02/89 
 Adjuster: Jennifer Restori 
 Claim # 
 00546184961-WC-01 
 Phone # 916-247-2436 
 doi: 
 25/01/20 
 Fax # 
 866-240-0248 
 Insurance: Gallagher Bassett (Corona) 
 Patient Info: 
 Address: 
 6351 Cody Manor Apt. 551
New Victoria, MH 69290
 Phone (C): 831-240-3249 
 Pref. Lang.: 
 English 
 Diagnosis: 
 M24.17 
 Intervertebral disc disorders with radiculopathy, lumbosacral region 
 Case Type: 
 Work Compensation 
 176 Eric Blair : Aug 25, 2022 
 page 12 
