Healthcare Provider Details

I. General information

NPI: 1215487723
Provider Name (Legal Business Name): ROBERT JOHNSON COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 10/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3005 APACHE DR
JONESBORO AR
72401-7432
US

IV. Provider business mailing address

3005 APACHE DR
JONESBORO AR
72401-7432
US

V. Phone/Fax

Practice location:
  • Phone: 870-336-0238
  • Fax: 870-336-0239
Mailing address:
  • Phone: 870-336-0238
  • Fax: 870-336-0239

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOT2016-036
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: