Healthcare Provider Details

I. General information

NPI: 1639650732
Provider Name (Legal Business Name): HERIBERTO 'EDDIE' RAMIREZ MARTINEZ COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12021 METRIC BLVD
AUSTIN TX
78758
US

IV. Provider business mailing address

12302 UNIT B WILLOW WILD DR.
AUSTIN TX
78758
US

V. Phone/Fax

Practice location:
  • Phone: 512-228-3300
  • Fax:
Mailing address:
  • Phone: 936-590-8251
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number213800
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: