Healthcare Provider Details

I. General information

NPI: 1700439601
Provider Name (Legal Business Name): RACHEL LYNN WYLES-DE RYK COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9518 9TH ST STE C-1
RANCHO CUCAMONGA CA
91730-4568
US

IV. Provider business mailing address

15444 ROCHELLE ST
FONTANA CA
92336-1030
US

V. Phone/Fax

Practice location:
  • Phone: 909-443-9919
  • Fax:
Mailing address:
  • Phone: 909-368-7623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA4879
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: