MEDICARE: MS. TYRENE L CHRISTOPULOS OT

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	6078767-4201	UT

General Provider Information

NPI Number	:	1790925394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TYRENE L CHRISTOPULOS OT

Provider Business Mailing Address
First Line	:	2760 RASMUSSEN RD
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5684
Country	:	US
Telephone Number	:	801-232-9349
Fax Number	:

Provider Business Practice Location Address
First Line	:	2760 RASMUSSEN RD
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5684
Country	:	US
Telephone Number	:	801-232-9349
Fax Number	:

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

Provider Enumeration Date	:	02/23/2009
Last Update Date	:	02/23/2009

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