MEDICARE: MR. GIAN CARLO CORTEZ ENRIQUEZ COTAL

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	224Z00000X	Occupational Therapy Assistant	5202008343	MI

General Provider Information

NPI Number	:	1134712474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GIAN CARLO CORTEZ ENRIQUEZ COTAL

Provider Business Mailing Address
First Line	:	13657 MARTIN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48088-4304
Country	:	US
Telephone Number	:	586-337-1009
Fax Number	:

Provider Business Practice Location Address
First Line	:	13657 MARTIN RD
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48088-4304
Country	:	US
Telephone Number	:	586-337-1009
Fax Number	:

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

Provider Enumeration Date	:	02/18/2021
Last Update Date	:	02/18/2021

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