=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427233378
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GINGER MICHEL POGUE MOT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2008
-----------------------------------------------------
Last Update Date | 01/09/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11201 BENTON ST
-----------------------------------------------------
City | LOMA LINDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92357-1000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-825-7084
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23016 VISTA GRANDE WAY
-----------------------------------------------------
City | GRAND TERRACE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92313-4936
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-370-0427
-----------------------------------------------------
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 | 9805
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------