Healthcare Provider Details

I. General information

NPI: 1588085526
Provider Name (Legal Business Name): JAMES EDWIN GUTIERREZ COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2013
Last Update Date: 12/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 WILLOW TRL
BOSQUE FARMS NM
87068-9054
US

IV. Provider business mailing address

1260 WILLOW TRL
BOSQUE FARMS NM
87068-9054
US

V. Phone/Fax

Practice location:
  • Phone: 505-379-7695
  • Fax:
Mailing address:
  • Phone: 505-379-7695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number851
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: