MEDICARE: MRS. PINKY RALLANG STA MARIA OTR

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	OT16387	FL

General Provider Information

NPI Number	:	1376031096
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PINKY RALLANG STA MARIA OTR

Provider Business Mailing Address
First Line	:	10605 MOORE RD
Second Line	:
City	:	GOTHA
State	:	FL
Zip	:	34734-4704
Country	:	US
Telephone Number	:	407-495-8840
Fax Number	:

Provider Business Practice Location Address
First Line	:	10605 MOORE RD
Second Line	:
City	:	GOTHA
State	:	FL
Zip	:	34734-4704
Country	:	US
Telephone Number	:	407-495-8840
Fax Number	:

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

Provider Enumeration Date	:	04/27/2018
Last Update Date	:	04/27/2018

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