=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205617511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OT OF MICHIGAN INC,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2023
-----------------------------------------------------
Last Update Date | 11/02/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1120 E LONG LAKE RD STE 101
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-4974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-234-8617
-----------------------------------------------------
Fax | 248-928-0463
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1120 E LONG LAKE RD STE 101
-----------------------------------------------------
City | TROY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48085-4974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-234-8617
-----------------------------------------------------
Fax | 248-928-0463
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | VIAN KOMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-234-8617
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------