=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073718367
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEREMY BRAD KING COTA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1504 N 1ST ST
-----------------------------------------------------
City | HASKELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79521-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 940-864-2932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 190 SUGAR BISCUIT LN
-----------------------------------------------------
City | ABILENE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79602-5546
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 325-698-5045
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 224Z00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapy Assistant
-----------------------------------------------------
License Number | 208771
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------