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General NPI Number Information
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NPI Number | 1083336630
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Entity Type | Individual
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Provider Name | OMAR MEDINA COTAL
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Gender | Male
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Dates
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Enumeration Date | 09/12/2022
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Last Update Date | 09/12/2022
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Provider Practice Location Address
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Address Line | 235 DUNLOP FARMS BLVD
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City | COLONIAL HEIGHTS
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State | VA
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Zip | 23834-1792
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Country | US
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Telephone | 804-937-4096
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Fax |
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Provider Business Mailing Address
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Address Line | 3331 APPLEFORD DR
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City | CHESTER
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State | VA
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Zip | 23831-7091
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Country | US
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Telephone | 804-937-4096
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 0131002-093
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License Number State | VA
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