Healthcare Provider Details

I. General information

NPI: 1760142038
Provider Name (Legal Business Name): OMAR VILLA COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 12/28/2021
Certification Date: 12/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 E NIZHONI BLVD
GALLUP NM
87301-5744
US

IV. Provider business mailing address

224 E NIZHONI BLVD
GALLUP NM
87301-5744
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-9551
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA4506
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: