Healthcare Provider Details

I. General information

NPI: 1609393321
Provider Name (Legal Business Name): ROBERT FLY COTA/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 08/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8017 DOGWOOD LN
MILAN TN
38358-6805
US

IV. Provider business mailing address

187 MILAN HWY
MILAN TN
38358-6035
US

V. Phone/Fax

Practice location:
  • Phone: 731-686-8373
  • Fax:
Mailing address:
  • Phone: 731-693-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberOTA0000002906
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: