Healthcare Provider Details

I. General information

NPI: 1851781132
Provider Name (Legal Business Name): FAYE WOODRUFF COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1318 S CHIPMAN ST
OWOSSO MI
48867-4163
US

IV. Provider business mailing address

1318 S CHIPMAN ST
OWOSSO MI
48867-4163
US

V. Phone/Fax

Practice location:
  • Phone: 919-624-0482
  • Fax:
Mailing address:
  • Phone: 919-624-0482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number5202007897
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: