Healthcare Provider Details

I. General information

NPI: 1487851739
Provider Name (Legal Business Name): GREGORY ALLEN GARVIN COTA
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

416 HUNTINGTON DR
JACKSON MS
39272-4486
US

IV. Provider business mailing address

416 HUNTINGTON DR 865 NORTH ST
JACKSON MS
39272
US

V. Phone/Fax

Practice location:
  • Phone: 601-371-1800
  • Fax:
Mailing address:
  • Phone: 601-613-4911
  • Fax: 601-948-6651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA1475
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: