=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023093408
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIV. OF CA., DAVIS MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4860 Y ST SUITE 1100
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95817-2307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-734-6716
-----------------------------------------------------
Fax | 916-734-6706
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4305 EUCLID AVE
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95822-1040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-448-8421
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OTRIII
-----------------------------------------------------
Name | MS. PATRICIA PADIA WATTERS
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 916-734-6716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225XP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Occupational Therapist
-----------------------------------------------------
License Number | 4016
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------