Healthcare Provider Details

I. General information

NPI: 1578199824
Provider Name (Legal Business Name): GABE E. PEREZ COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2020
Last Update Date: 03/19/2020
Certification Date: 03/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3720 CHURCH ROCK ST
GALLUP NM
87301-4572
US

IV. Provider business mailing address

3720 CHURCH ROCK ST
GALLUP NM
87301-4572
US

V. Phone/Fax

Practice location:
  • Phone: 505-722-2261
  • Fax:
Mailing address:
  • Phone: 505-722-2261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA2834
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: