MEDICARE: MARTIN LAGO

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	224Z00000X	Occupational Therapy Assistant	3001	CA

General Provider Information

NPI Number	:	1972992667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTIN LAGO

Provider Business Mailing Address
First Line	:	405 N MADISON AVE
Second Line	:	UNIT 9
City	:	PASADENA
State	:	CA
Zip	:	91101-1439
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5310 FOUNTAIN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90029-1005
Country	:	US
Telephone Number	:	323-461-9961
Fax Number	:

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

Provider Enumeration Date	:	01/18/2015
Last Update Date	:	01/18/2015

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Directions to “ MARTIN LAGO ” Practice Location

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