Active NPI
Andrew Melbon Gultom, COTA
- Occupational Therapy Assistant
- Banning, CA
National Provider Identifier
1518159409
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Occupational Therapy Assistant
- License
- 1013
- Practice address
- 1065 Driftwood Cir
Banning, CA 92220-6321 - Phone
- (909) 856-6625
- Fax
- (877) 799-9128
- NPI assigned
- Aug 14, 2007
- Last updated
- Aug 14, 2007
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Occupational Therapy Assistant | 224Z00000X | 1013 | CA | Primary |
Addresses
Primary practice location
1065 Driftwood Cir
Banning, CA 92220-6321
Mailing address
1065 Driftwood Cir
Banning, CA 92220-6321
Phone (909) 856-6625
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 1013 | CA | MD | Occupational Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1187049600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1187049600000",
"number": "1518159409",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1065 DRIFTWOOD CIR",
"city": "BANNING",
"state": "CA",
"postal_code": "922206321",
"telephone_number": "909-856-6625",
"fax_number": "877-799-9128"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1065 DRIFTWOOD CIR",
"city": "BANNING",
"state": "CA",
"postal_code": "922206321",
"telephone_number": "909-856-6625",
"fax_number": "877-799-9128"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GULTOM",
"first_name": "ANDREW",
"middle_name": "MELBON",
"name_prefix": "Mr.",
"credential": "COTA",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-08-14",
"last_updated": "2007-08-14",
"status": "A"
},
"taxonomies": [
{
"code": "224Z00000X",
"taxonomy_group": "",
"desc": "Occupational Therapy Assistant",
"state": "CA",
"license": "1013",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Banning, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 14, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.