MEDICARE: DR. JAMIE LEE GUANGCO OTD/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	31006701A	IN

General Provider Information

NPI Number	:	1922562966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAMIE LEE GUANGCO OTD/OTR

Provider Business Mailing Address
First Line	:	2804 TUMBLEWEED DR
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46901-4090
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 N MERIDIAN ST
Second Line	:
City	:	GREENTOWN
State	:	IN
Zip	:	46936-1246
Country	:	US
Telephone Number	:	765-628-3377
Fax Number	:

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

Provider Enumeration Date	:	01/23/2019
Last Update Date	:	01/23/2019

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