MEDICARE: MRS. MICHELLE LARA KIM O.T.R./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	174400000X	Specialist	OT 2282	CA

General Provider Information

NPI Number	:	1851535413
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MICHELLE LARA KIM O.T.R./L

Provider Business Mailing Address
First Line	:	26430 MARGARITA LN
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92354-6741
Country	:	US
Telephone Number	:	909-210-3892
Fax Number	:

Provider Business Practice Location Address
First Line	:	9161 SIERRA AVE
Second Line	:	SUITE 111
City	:	FONTANA
State	:	CA
Zip	:	92335-4729
Country	:	US
Telephone Number	:	909-427-4073
Fax Number	:

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

Provider Enumeration Date	:	04/27/2009
Last Update Date	:	11/18/2021

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