Provider Demographics
NPI:1255863361
Name:CANEZAL, VINCENT ELMO (COTA)
Entity Type:Individual
Prefix:
First Name:VINCENT
Middle Name:ELMO
Last Name:CANEZAL
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:VINCENT
Other - Middle Name:ELMO F
Other - Last Name:CANEZAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5135 OXFORD LN
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91762-7232
Mailing Address - Country:US
Mailing Address - Phone:909-438-5887
Mailing Address - Fax:
Practice Address - Street 1:5135 OXFORD LN
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91762-7232
Practice Address - Country:US
Practice Address - Phone:909-438-5887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-29
Last Update Date:2017-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOTA3767224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant