Healthcare Provider Details

I. General information

NPI: 1023159779
Provider Name (Legal Business Name): GEORGE JAMES MATA JR. COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: GEORGE JAMES SALAMUNEC JR. COTA/L

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10251 N 35TH AVE
PHOENIX AZ
85051-1305
US

IV. Provider business mailing address

222 W CLARENDON AVE APT 207 APT #207
PHOENIX AZ
85013-3487
US

V. Phone/Fax

Practice location:
  • Phone: 602-995-0867
  • Fax:
Mailing address:
  • Phone: 602-516-0162
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1917
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: