MEDICARE: OT ETC, INC

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	174400000X	Specialist	OT 5207	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	ZZZ09152Z	OTHER	CA	BLUE SHIELD PIN

General Provider Information

NPI Number	:	1487671210
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OT ETC, INC

Provider Business Mailing Address
First Line	:	7927 OSTROW ST STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3604
Country	:	US
Telephone Number	:	858-565-6910
Fax Number	:

Provider Business Practice Location Address
First Line	:	7927 OSTROW ST STE B
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92111-3604
Country	:	US
Telephone Number	:	858-565-6910
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	VALERIE E PLUMMER
Credential	:	OTR
Telephone Number	:	858-565-6910

Provider Enumeration Date	:	07/17/2006
Last Update Date	:	08/22/2020

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Directions to “OT ETC, INC ” Practice Location

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