Healthcare Provider Details

I. General information

NPI: 1649583824
Provider Name (Legal Business Name): EDDIE LEELOVE KUYKENDALL III COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/16/2010
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13835 N TATUM BLVD STE 9-429
PHOENIX AZ
85032-5590
US

IV. Provider business mailing address

7519 N 47TH LN
GLENDALE AZ
85301-1576
US

V. Phone/Fax

Practice location:
  • Phone: 480-242-5903
  • Fax:
Mailing address:
  • Phone: 602-301-5592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number3353
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: