Healthcare Provider Details

I. General information

NPI: 1366714917
Provider Name (Legal Business Name): WILLIAM D PENNER COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/29/2012
Last Update Date: 01/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3734 PIEDRAS NEGRAS DR
LAS CRUCES NM
88012-7671
US

IV. Provider business mailing address

3734 PIEDRAS NEGRAS DR
LAS CRUCES NM
88012-7671
US

V. Phone/Fax

Practice location:
  • Phone: 575-642-0920
  • Fax:
Mailing address:
  • Phone: 575-642-0920
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2505
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: