Healthcare Provider Details

I. General information

NPI: 1700376761
Provider Name (Legal Business Name): JOSE DAVID OBRIEN COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7000 N MCCORMICK BLVD
LINCOLNWOOD IL
60712-2726
US

IV. Provider business mailing address

7000 N MCCORMICK BLVD
LINCOLNWOOD IL
60712-2726
US

V. Phone/Fax

Practice location:
  • Phone: 847-673-7166
  • Fax:
Mailing address:
  • Phone: 847-673-7166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number057003730
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: