Healthcare Provider Details

I. General information

NPI: 1487843421
Provider Name (Legal Business Name): VICTORIA LEE LAWSON COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2007
Last Update Date: 10/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11210 95TH ST
COAL VALLEY IL
61240-9360
US

IV. Provider business mailing address

102 MAIN ST P.O. BOX 214
OPHIEM IL
61468-9501
US

V. Phone/Fax

Practice location:
  • Phone: 309-799-3161
  • Fax: 309-799-5904
Mailing address:
  • Phone: 309-629-8902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: