=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346785078
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JESSE LIMON
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2017
-----------------------------------------------------
Last Update Date | 01/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 919 N SUNSET AVE
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91790-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-692-4489
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13663 DICKY ST
-----------------------------------------------------
City | WHITTIER
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90605-2950
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 3380
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------