MEDICARE: WAYNE BRIAN CENTRA MOTR/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	225X00000X	Occupational Therapist	OT-5499	CA

General Provider Information

NPI Number	:	1841582020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WAYNE BRIAN CENTRA MOTR/L

Provider Business Mailing Address
First Line	:	3002 DOW AVE
Second Line	:	114
City	:	TUSTIN
State	:	CA
Zip	:	92780-7233
Country	:	US
Telephone Number	:	714-731-4668
Fax Number	:	714-464-4668

Provider Business Practice Location Address
First Line	:	3002 DOW AVE
Second Line	:	114
City	:	TUSTIN
State	:	CA
Zip	:	92780-7233
Country	:	US
Telephone Number	:	714-731-4668
Fax Number	:	714-464-4668

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

Provider Enumeration Date	:	05/06/2011
Last Update Date	:	04/20/2017

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