=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912009648
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD CARLTON O.T.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1971 E 4TH ST 210
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-3917
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-835-1672
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3204 E JACARANDA AVE
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92867-7569
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 30
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------