MEDICARE: LISA RUTH MEDVENE COTA

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	224Z00000X	Occupational Therapy Assistant	1847	CA

General Provider Information

NPI Number	:	1225427115
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA RUTH MEDVENE COTA

Provider Business Mailing Address
First Line	:	25501 POLARIS LN
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-4921
Country	:	US
Telephone Number	:	714-222-5748
Fax Number	:

Provider Business Practice Location Address
First Line	:	25501 POLARIS LN
Second Line	:
City	:	LAKE FOREST
State	:	CA
Zip	:	92630-4921
Country	:	US
Telephone Number	:	714-222-5748
Fax Number	:

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

Provider Enumeration Date	:	01/15/2015
Last Update Date	:	01/15/2015

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