MEDICARE: MR. CHRISTOPHER ANDRE BEAVERS 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	2010021288	MO

General Provider Information

NPI Number	:	1760743991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHRISTOPHER ANDRE BEAVERS COTA/L

Provider Business Mailing Address
First Line	:	4626 WHISPER LAKE DR
Second Line	:
City	:	FLORISSANT
State	:	MO
Zip	:	63033-4307
Country	:	US
Telephone Number	:	314-680-9510
Fax Number	:

Provider Business Practice Location Address
First Line	:	4335 W PINE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2205
Country	:	US
Telephone Number	:	314-371-0200
Fax Number	:

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

Provider Enumeration Date	:	06/05/2012
Last Update Date	:	06/05/2012

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