=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992127898
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG DOUGLAS MOREA C.O.T.A.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/10/2014
-----------------------------------------------------
Last Update Date | 01/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 707 ARMSTRONG RD
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48911-3906
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-393-5814
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5057 RAY RD
-----------------------------------------------------
City | LINDEN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48451-9460
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-265-9226
-----------------------------------------------------
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 | 5202007627
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------