Healthcare Provider Details

I. General information

NPI: 1477833580
Provider Name (Legal Business Name): FRANK M. GUSTAMANTES COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2011
Last Update Date: 08/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 N RICHARDSON AVE
ROSWELL NM
88201-4639
US

IV. Provider business mailing address

304 N RICHARDSON AVE
ROSWELL NM
88201-4639
US

V. Phone/Fax

Practice location:
  • Phone: 575-578-0069
  • Fax: 575-578-0124
Mailing address:
  • Phone: 575-578-0069
  • Fax: 575-578-0124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2126
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: