Healthcare Provider Details

I. General information

NPI: 1700369592
Provider Name (Legal Business Name): NICOLE RAE MARISCAL COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2018
Last Update Date: 09/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17042 BELLFLOWER BLVD
BELLFLOWER CA
90706-5950
US

IV. Provider business mailing address

17042 BELLFLOWER BLVD
BELLFLOWER CA
90706-5950
US

V. Phone/Fax

Practice location:
  • Phone: 562-991-1324
  • Fax:
Mailing address:
  • Phone: 562-991-1324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4453
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: