MEDICARE: MR. DARRYL TAD TANAKA OTR/L

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	225XE0001X	Environmental Modification Occupational Therapist	OT 6588	CA

General Provider Information

NPI Number	:	1205070323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DARRYL TAD TANAKA OTR/L

Provider Business Mailing Address
First Line	:	12051 CHAUCER RD
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-4531
Country	:	US
Telephone Number	:	562-596-3668
Fax Number	:

Provider Business Practice Location Address
First Line	:	12051 CHAUCER RD
Second Line	:
City	:	LOS ALAMITOS
State	:	CA
Zip	:	90720-4531
Country	:	US
Telephone Number	:	562-596-3668
Fax Number	:

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

Provider Enumeration Date	:	04/21/2009
Last Update Date	:	04/21/2009

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