Healthcare Provider Details

I. General information

NPI: 1174720445
Provider Name (Legal Business Name): JIMMY DALE BRANNON COTA,L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 MAIN
FORDSVILLE KY
42343
US

IV. Provider business mailing address

813 BROAD ST
CENTRAL KY
42330
US

V. Phone/Fax

Practice location:
  • Phone: 270-276-5435
  • Fax:
Mailing address:
  • Phone: 270-754-5280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA3397
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: