Healthcare Provider Details

I. General information

NPI: 1518170638
Provider Name (Legal Business Name): TOMMY EDWARD MOLINA COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18219 W PORT AU PRINCE LN
SURPRISE AZ
85388-7568
US

IV. Provider business mailing address

18219 W PORT AU PRINCE LN
SURPRISE AZ
85388-7568
US

V. Phone/Fax

Practice location:
  • Phone: 623-214-2988
  • Fax:
Mailing address:
  • Phone: 623-214-2988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1506
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: