=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356822548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALMA FAJARDO OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2018
-----------------------------------------------------
Last Update Date | 08/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 N SCENIC HWY
-----------------------------------------------------
City | LAKE WALES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33853-3208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-676-1512
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9454 OXFORD DR
-----------------------------------------------------
City | WINTER HAVEN
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33884-4845
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-422-2405
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | OT14891
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------