Healthcare Provider Details

I. General information

NPI: 1649573445
Provider Name (Legal Business Name): RONALD KEITH CLOSE II COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2010
Last Update Date: 12/02/2022
Certification Date: 12/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 BEAR MOUNTAIN DR
KEYSER WV
26726-1806
US

IV. Provider business mailing address

122 BEAR MOUNTAIN DR
KEYSER WV
26726-1806
US

V. Phone/Fax

Practice location:
  • Phone: 304-617-5844
  • Fax:
Mailing address:
  • Phone: 304-617-5844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License NumberA01808
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberC 1756
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: