MEDICARE: IRIS G BARRIENTOS COTA/L

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	057004996	IL

General Provider Information

NPI Number	:	1821643180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IRIS G BARRIENTOS COTA/L

Provider Business Mailing Address
First Line	:	4538 N BEACON ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-5519
Country	:	US
Telephone Number	:	773-275-7200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1756 W ROSEHILL DR APT 1E
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60660-3933
Country	:	US
Telephone Number	:	773-807-9675
Fax Number	:

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

Provider Enumeration Date	:	08/05/2019
Last Update Date	:	08/05/2019

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