Healthcare Provider Details

I. General information

NPI: 1225474000
Provider Name (Legal Business Name): LAURA LEIGH TAKACH COTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 05/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8103 NORTH HOLW
SAN ANTONIO TX
78240-2387
US

IV. Provider business mailing address

1815 SOARING EAGLE DR
FISCHER TX
78623-1809
US

V. Phone/Fax

Practice location:
  • Phone: 210-558-9001
  • Fax: 210-558-9010
Mailing address:
  • Phone: 830-708-1256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number207982
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: