=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104102698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED OCCUPATIONAL THERAPY SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2011
-----------------------------------------------------
Last Update Date | 10/27/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17 N CHATSWORTH AVE APT. 4F
-----------------------------------------------------
City | LARCHMONT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10538-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-938-3302
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17 N CHATSWORTH AVE APT. 4F
-----------------------------------------------------
City | LARCHMONT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10538-2109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. JOHN EBOLI
-----------------------------------------------------
Credential | OTR/L
-----------------------------------------------------
Telephone | 718-938-3302
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------