Healthcare Provider Details

I. General information

NPI: 1821547779
Provider Name (Legal Business Name): T'KARA LYNEES MCKINNEY COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2016
Last Update Date: 10/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 VIA CALLEJON STE B
SAN CLEMENTE CA
92673-6213
US

IV. Provider business mailing address

1120 VIA CALLEJON, STE B
SAN CLEMENTE CA
92673
US

V. Phone/Fax

Practice location:
  • Phone: 949-498-5100
  • Fax: 949-366-5665
Mailing address:
  • Phone: 949-498-5100
  • Fax: 949-366-5665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number00830163
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: