MEDICARE: MR. VICTOR MEDINA M.A. O.T.R

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	225X00000X	Occupational Therapist	6030	CA

General Provider Information

NPI Number	:	1083732283
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VICTOR MEDINA M.A. O.T.R

Provider Business Mailing Address
First Line	:	6315 PRIMROSE AVE APT 3
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90068-2873
Country	:	US
Telephone Number	:	310-871-7443
Fax Number	:

Provider Business Practice Location Address
First Line	:	4655 RUFFNER ST
Second Line	:	STE 270
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-2275
Country	:	US
Telephone Number	:	180-078-7678
Fax Number	:

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

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	10/06/2021

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