Healthcare Provider Details

I. General information

NPI: 1124972005
Provider Name (Legal Business Name): LEWIS BENJAMIN CHANDRY COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2026
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 TOM HUNTER RD
CHARLOTTE NC
28213-5511
US

IV. Provider business mailing address

1119 JILLS SPRING LN APT 202
CHARLOTTE NC
28269-3930
US

V. Phone/Fax

Practice location:
  • Phone: 704-598-5136
  • Fax:
Mailing address:
  • Phone: 772-323-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number9277
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: