Healthcare Provider Details

I. General information

NPI: 1063235018
Provider Name (Legal Business Name): MOSES ROQUE COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2024
Last Update Date: 11/06/2024
Certification Date: 11/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 S PRAIRIE AVE
PUEBLO CO
81005-2307
US

IV. Provider business mailing address

1321 S PRAIRIE AVE
PUEBLO CO
81005-2307
US

V. Phone/Fax

Practice location:
  • Phone: 719-569-4411
  • Fax:
Mailing address:
  • Phone: 719-569-4411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA.0000098
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: