Healthcare Provider Details

I. General information

NPI: 1386123230
Provider Name (Legal Business Name): JOSE ACOSTA COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2018
Last Update Date: 08/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 W ALLUVIAL AVE
CLOVIS CA
93611-6716
US

IV. Provider business mailing address

3750 N FRESNO ST APT 143
FRESNO CA
93726-5505
US

V. Phone/Fax

Practice location:
  • Phone: 559-323-6200
  • Fax:
Mailing address:
  • Phone: 305-746-1613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4436
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: