Healthcare Provider Details

I. General information

NPI: 1073854675
Provider Name (Legal Business Name): CHRISTOPHER DALE SIMMONS COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2013
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2888 LERA JONES DR
ANTIOCH TN
37013-1317
US

IV. Provider business mailing address

2888 LERA JONES DR
ANTIOCH TN
37013-1317
US

V. Phone/Fax

Practice location:
  • Phone: 615-712-9626
  • Fax:
Mailing address:
  • Phone: 615-712-9626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA0000001463
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: