Healthcare Provider Details

I. General information

NPI: 1720983877
Provider Name (Legal Business Name): LUKE KONGMHONG MOUA COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11588 VIA RANCHO SAN DIEGO
EL CAJON CA
92019-5277
US

IV. Provider business mailing address

10337 VISTA DEL CAPITAN
LAKESIDE CA
92040-2523
US

V. Phone/Fax

Practice location:
  • Phone: 858-533-1291
  • Fax:
Mailing address:
  • Phone: 619-201-0902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number7639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: