Healthcare Provider Details

I. General information

NPI: 1770684763
Provider Name (Legal Business Name): KIM OANH DWORZANOWSKI COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 LAURENS ST
AIKEN SC
29801-3416
US

IV. Provider business mailing address

3114 CHELSEA DR
AUGUSTA GA
30909-3314
US

V. Phone/Fax

Practice location:
  • Phone: 803-649-6264
  • Fax:
Mailing address:
  • Phone: 706-736-0901
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number2629
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: