Healthcare Provider Details

I. General information

NPI: 1295851970
Provider Name (Legal Business Name): ANTHONY JAY EZELL COTAL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 MAIN ST.
MEADVILLE MS
39653
US

IV. Provider business mailing address

9230 BERRYTOWN RD SE
MEADVILLE MS
39653-9035
US

V. Phone/Fax

Practice location:
  • Phone: 601-384-1898
  • Fax: 601-384-1878
Mailing address:
  • Phone: 601-384-1562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberTA1041
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: