Healthcare Provider Details

I. General information

NPI: 1730831785
Provider Name (Legal Business Name): ANDREW VALLADARES COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2022
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST STE 249
LAS CRUCES NM
88001-1243
US

IV. Provider business mailing address

505 S MAIN ST
LAS CRUCES NM
88001-1206
US

V. Phone/Fax

Practice location:
  • Phone: 575-527-5823
  • Fax: 575-527-5886
Mailing address:
  • Phone: 575-527-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number4124
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: