MEDICARE: MS. MARIBEL ACOSTA OTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174H00000X	Health Educator	007687-1	NY

General Provider Information

NPI Number	:	1063728830
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARIBEL ACOSTA OTA

Provider Business Mailing Address
First Line	:	3925 24TH ST
Second Line	:	12
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3933
Country	:	US
Telephone Number	:	718-472-0887
Fax Number	:

Provider Business Practice Location Address
First Line	:	3925 24TH ST
Second Line	:	12
City	:	LONG ISLAND CITY
State	:	NY
Zip	:	11101-3933
Country	:	US
Telephone Number	:	718-472-0887
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2010
Last Update Date	:	08/31/2010

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