MEDICARE: SAMUEL DOMINIC ZUCCALA OTR

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	225X00000X	Occupational Therapist	5201009962	MI

General Provider Information

NPI Number	:	1366951642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL DOMINIC ZUCCALA OTR

Provider Business Mailing Address
First Line	:	1739 STOCKMAN RD
Second Line	:
City	:	MT PLEASANT
State	:	MI
Zip	:	48858-4218
Country	:	US
Telephone Number	:	734-476-6323
Fax Number	:

Provider Business Practice Location Address
First Line	:	2532 W CADILLAC DR
Second Line	:
City	:	FARWELL
State	:	MI
Zip	:	48622-9757
Country	:	US
Telephone Number	:	989-588-9928
Fax Number	:

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

Provider Enumeration Date	:	09/29/2017
Last Update Date	:	09/29/2017

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