Healthcare Provider Details

I. General information

NPI: 1538498464
Provider Name (Legal Business Name): CARLA JANE STEVENS COTA/L
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/24/2009
Last Update Date: 12/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 HIGHWOOD STREET
WATERVILLE ME
04901
US

IV. Provider business mailing address

365 QUAKER RD
SIDNEY ME
04330-2306
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-0705
  • Fax:
Mailing address:
  • Phone: 207-215-3019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberOA1795
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: