Healthcare Provider Details

I. General information

NPI: 1518256882
Provider Name (Legal Business Name): AVIE B. MOORE COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1071 EAGLERIDGE BLVD.
PUEBLO CO
81008
US

IV. Provider business mailing address

8540 SCARBOROUGH DR. SUITE 200
COLO SPRINGS CO
80920
US

V. Phone/Fax

Practice location:
  • Phone: 719-583-0832
  • Fax: 719-583-0797
Mailing address:
  • Phone: 719-630-7500
  • Fax: 719-630-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number234835
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: