Individual
MR. ANDREW MELBON GULTOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
COTA
Contact information
Practice address
1065 DRIFTWOOD CIR, BANNING, CA 92220-6321
(909) 856-6625
(877) 799-9128
Mailing address
1065 DRIFTWOOD CIR, BANNING, CA 92220-6321
(909) 856-6625
(877) 799-9128
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
1013
CA
Other
Enumeration date
08/14/2007
Last updated
08/14/2007
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