Healthcare Provider Details

I. General information

NPI: 1932363736
Provider Name (Legal Business Name): SHANE BURGESS COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2008
Last Update Date: 07/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S EADS AVE
PARIS IL
61944-1938
US

IV. Provider business mailing address

3812 WESTERN AVE
MATTOON IL
61938-2044
US

V. Phone/Fax

Practice location:
  • Phone: 217-465-5395
  • Fax:
Mailing address:
  • Phone: 217-273-3998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number057.002001
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: