MEDICARE: MS. EDITH M MAK 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	225XP0200X	Pediatric Occupational Therapist	855	CA

General Provider Information

NPI Number	:	1609900257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. EDITH M MAK OTR

Provider Business Mailing Address
First Line	:	PO BOX 64855
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-0855
Country	:	US
Telephone Number	:	310-790-4292
Fax Number	:	310-470-5971

Provider Business Practice Location Address
First Line	:	2355 WESTWOOD BLVD
Second Line	:	#703
City	:	LOS ANGELES
State	:	CA
Zip	:	90064-2109
Country	:	US
Telephone Number	:	310-790-4292
Fax Number	:	310-470-5971

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

Provider Enumeration Date	:	03/15/2007
Last Update Date	:	12/08/2009

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