Healthcare Provider Details

I. General information

NPI: 1336777408
Provider Name (Legal Business Name): LANCE BERESFORD COTA/L, DRS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2020
Last Update Date: 04/01/2020
Certification Date: 04/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PENN AVE STE 308
DES MOINES IA
50316-2368
US

IV. Provider business mailing address

1200 PLEASANT ST
DES MOINES IA
50309-1406
US

V. Phone/Fax

Practice location:
  • Phone: 515-263-5143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code224ZR0403X
TaxonomyDriving and Community Mobility Occupational Therapy Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: