Healthcare Provider Details

I. General information

NPI: 1396419818
Provider Name (Legal Business Name): JEREMY LUENA COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/07/2021
Last Update Date: 08/07/2021
Certification Date: 08/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 HOEN AVE
SANTA ROSA CA
95405-9407
US

IV. Provider business mailing address

910 KAY AVE
TRINIDAD CA
95570-9727
US

V. Phone/Fax

Practice location:
  • Phone: 707-546-0471
  • Fax:
Mailing address:
  • Phone: 860-301-4739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number5317
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: