Healthcare Provider Details

I. General information

NPI: 1508539875
Provider Name (Legal Business Name): ANTONIO ROQUE JR. COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2021
Last Update Date: 07/31/2021
Certification Date: 07/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 SW 156TH PL
MIAMI FL
33185-4169
US

IV. Provider business mailing address

5140 SW 156TH PL
MIAMI FL
33185-4169
US

V. Phone/Fax

Practice location:
  • Phone: 786-376-5110
  • Fax:
Mailing address:
  • Phone: 786-376-5110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number17114
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: