Provider Demographics
NPI:1720762735
Name:ALTAMIRANO, ISMARI ROSALEY (OTR/L)
Entity Type:Individual
Prefix:
First Name:ISMARI
Middle Name:ROSALEY
Last Name:ALTAMIRANO
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23034 PEACOCK CT
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5339
Mailing Address - Country:US
Mailing Address - Phone:909-343-2316
Mailing Address - Fax:
Practice Address - Street 1:275 W HOSPITALITY LN STE 100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3238
Practice Address - Country:US
Practice Address - Phone:909-567-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25060225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist