Healthcare Provider Details

I. General information

NPI: 1518543313
Provider Name (Legal Business Name): OTIQUE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

644 N HOBART BLVD APT 7
LOS ANGELES CA
90004-3098
US

IV. Provider business mailing address

644 N HOBART BLVD APT 7
LOS ANGELES CA
90004-3098
US

V. Phone/Fax

Practice location:
  • Phone: 904-219-1523
  • Fax:
Mailing address:
  • Phone: 904-219-1523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: KIMYATTA SHARDIA WASHINGTON
Title or Position: MANAGER
Credential: OTR/L
Phone: 904-219-1523