Healthcare Provider Details

I. General information

NPI: 1093800070
Provider Name (Legal Business Name): JOHN BOGARDUS I COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 S MANNING BLVD
ALBANY NY
12208-1771
US

IV. Provider business mailing address

310 S MANNING BLVD
ALBANY NY
12208-1771
US

V. Phone/Fax

Practice location:
  • Phone: 518-525-1372
  • Fax: 518-525-1120
Mailing address:
  • Phone: 518-525-1372
  • Fax: 518-525-1120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number004356-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: