MEDICARE: MR. RANDY ROY SMITH COTA/L

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	A02807	MD

General Provider Information

NPI Number	:	1164079331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RANDY ROY SMITH COTA/L

Provider Business Mailing Address
First Line	:	3100 NW 39TH ST
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33309-4918
Country	:	US
Telephone Number	:	954-513-8184
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 NW 39TH ST
Second Line	:
City	:	LAUDERDALE LAKES
State	:	FL
Zip	:	33309-4918
Country	:	US
Telephone Number	:	954-513-8184
Fax Number	:

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

Provider Enumeration Date	:	08/22/2019
Last Update Date	:	08/22/2019

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