Healthcare Provider Details

I. General information

NPI: 1447594064
Provider Name (Legal Business Name): KEVIN D LYNN COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1019 3RD AVE S
PAYETTE ID
83661-2832
US

IV. Provider business mailing address

808 SW 8TH ST
FRUITLAND ID
83619-2527
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-4455
  • Fax: 208-642-1315
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224ZE0001X
TaxonomyEnvironmental Modification Occupational Therapy Assistant
License Number
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code224ZF0002X
TaxonomyFeeding, Eating & Swallowing Occupational Therapy Assistant
License NumberOTA-117
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: