Healthcare Provider Details

I. General information

NPI: 1700350329
Provider Name (Legal Business Name): ROBERTO GENARO BANUELAS COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2019
Last Update Date: 01/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 N SEMORAN BLVD
WINTER PARK FL
32792-2840
US

IV. Provider business mailing address

30021 STATE ROAD 44
EUSTIS FL
32736-9287
US

V. Phone/Fax

Practice location:
  • Phone: 407-679-1515
  • Fax:
Mailing address:
  • Phone: 352-818-7720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA14506
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: