Healthcare Provider Details

I. General information

NPI: 1407050529
Provider Name (Legal Business Name): ROBERT RANDALL HENDRICKSON COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W BLANCHARD AVE
SOUTH HUTCHINSON KS
67505-1526
US

IV. Provider business mailing address

4507 FOOTHILL DR
HUTCHINSON KS
67502-4613
US

V. Phone/Fax

Practice location:
  • Phone: 620-663-7175
  • Fax:
Mailing address:
  • Phone: 620-728-0300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number18-00192
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: