Healthcare Provider Details

I. General information

NPI: 1003204876
Provider Name (Legal Business Name): DELBERT DEWAYNE PORTER COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2015
Last Update Date: 01/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

787 CRUTCH CREEK LN
DUNGANNON VA
24245-3950
US

IV. Provider business mailing address

787 CRUTCH CREEK LN
DUNGANNON VA
24245-3950
US

V. Phone/Fax

Practice location:
  • Phone: 276-467-1164
  • Fax:
Mailing address:
  • Phone: 276-467-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number0131000167
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: