Healthcare Provider Details

I. General information

NPI: 1316364227
Provider Name (Legal Business Name): GENEICE COOPER COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2014
Last Update Date: 03/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 S ROWLAND ST
CASSOPOLIS MI
49031-1350
US

IV. Provider business mailing address

221 S ROWLAND ST
CASSOPOLIS MI
49031-1350
US

V. Phone/Fax

Practice location:
  • Phone: 269-635-8512
  • Fax:
Mailing address:
  • Phone: 269-635-8512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number5202006918
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: