=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104510452
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ISAAC C ANZALONE COTA/L
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2023
-----------------------------------------------------
Last Update Date | 07/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1204 E BASELINE RD STE 106
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-1447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-582-0142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5102 N TORTOLITA RD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85745-9486
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-820-7374
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | OTA-046592
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------