Healthcare Provider Details

I. General information

NPI: 1730429960
Provider Name (Legal Business Name): ED TYBURSKI COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2013
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18480 COCHRAN BLVD
PORT CHARLOTTE FL
33948-3379
US

IV. Provider business mailing address

6279 COLISEUM BLVD
PORT CHARLOTTE FL
33981-6182
US

V. Phone/Fax

Practice location:
  • Phone: 941-743-4700
  • Fax:
Mailing address:
  • Phone: 941-380-5031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA6726
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: