Healthcare Provider Details

I. General information

NPI: 1114308954
Provider Name (Legal Business Name): LUCILLE GLOVER COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 06/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 COMMONWEALTH AVE
WARWICK RI
02886-2707
US

IV. Provider business mailing address

25 PRESCOTT AVE
RIVERSIDE RI
02915-1919
US

V. Phone/Fax

Practice location:
  • Phone: 401-739-4241
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number256
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: