Healthcare Provider Details

I. General information

NPI: 1366787574
Provider Name (Legal Business Name): KEYTA ROMOND RANKINS COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1833 CLIFTON RD
ATLANTA GA
30329
US

IV. Provider business mailing address

1833 CLIFTON RD
ATLANTA GA
30329
US

V. Phone/Fax

Practice location:
  • Phone: 251-382-8541
  • Fax:
Mailing address:
  • Phone: 251-382-8541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA001119
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: