Healthcare Provider Details

I. General information

NPI: 1619782398
Provider Name (Legal Business Name): IRVIN ALEXIS GUZMAN COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25652 OLD TRABUCO RD
LAKE FOREST CA
92630-2776
US

IV. Provider business mailing address

21022 LOS ALISOS BLVD APT 1816
RANCHO SANTA MARGARITA CA
92688-3262
US

V. Phone/Fax

Practice location:
  • Phone: 949-380-9380
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: