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General NPI Number Information
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NPI Number | 1093113995
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Entity Type | Individual
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Provider Name | PATRICK DALE RUCH COTA/L
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Gender | Male
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Dates
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Enumeration Date | 12/09/2014
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Last Update Date | 12/09/2014
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Provider Practice Location Address
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Address Line | 166 WILDFLOWER LN
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City | EAGLE
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State | ID
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Zip | 83616-5947
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Country | US
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Telephone | 208-794-7286
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Fax |
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Provider Business Mailing Address
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Address Line | 166 WILDFLOWER LN
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City | EAGLE
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State | ID
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Zip | 83616-5947
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Country | US
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Telephone | 208-794-7286
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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 | 295012
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | OTA-1139
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 224Z00000X
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Taxonomy Name | Occupational Therapy Assistant
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License Number | 14-1230
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License Number State | NV
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