Healthcare Provider Details

I. General information

NPI: 1245441930
Provider Name (Legal Business Name): KIRT CARL VAN COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 EVERGREEN DR
EAST PROVIDENCE RI
02914-1503
US

IV. Provider business mailing address

140 RAPHAEL AVE
PROVIDENCE RI
02904-1309
US

V. Phone/Fax

Practice location:
  • Phone: 401-438-3250
  • Fax: 401-438-4813
Mailing address:
  • Phone: 508-269-5971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA00055
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: