Healthcare Provider Details

I. General information

NPI: 1891842878
Provider Name (Legal Business Name): MARK ALLEN EAMES COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 E 17TH ST SUITE 400
IDAHO FALLS ID
83404-6154
US

IV. Provider business mailing address

9402 S MARSH CREEK RD
MCCAMMON ID
83250-1695
US

V. Phone/Fax

Practice location:
  • Phone: 208-589-0807
  • Fax: 208-542-9577
Mailing address:
  • Phone: 208-254-9942
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA-100
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: