Healthcare Provider Details

I. General information

NPI: 1366951642
Provider Name (Legal Business Name): SAMUEL DOMINIC ZUCCALA OTR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2017
Last Update Date: 09/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2532 W CADILLAC DR
FARWELL MI
48622-9757
US

IV. Provider business mailing address

1739 STOCKMAN RD
MT PLEASANT MI
48858-4218
US

V. Phone/Fax

Practice location:
  • Phone: 989-588-9928
  • Fax:
Mailing address:
  • Phone: 734-476-6323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201009962
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: