MEDICARE: MR. EFREN GOLLON 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	11826	CA

General Provider Information

NPI Number	:	1770940363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. EFREN GOLLON OTR

Provider Business Mailing Address
First Line	:	9321 PIONEER BLVD APT 205
Second Line	:
City	:	SANTA FE SPRINGS
State	:	CA
Zip	:	90670-8344
Country	:	US
Telephone Number	:	408-623-1510
Fax Number	:

Provider Business Practice Location Address
First Line	:	9321 PIONEER BLVD APT 205
Second Line	:
City	:	SANTA FE SPRINGS
State	:	CA
Zip	:	90670-8344
Country	:	US
Telephone Number	:	408-623-1510
Fax Number	:

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

Provider Enumeration Date	:	01/27/2016
Last Update Date	:	01/27/2016

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