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General NPI Number Information
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NPI Number | 1104247212
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Entity Type | Individual
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Provider Name | JOEL CLARK I COTA
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Gender | Male
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Dates
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Enumeration Date | 12/17/2013
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Last Update Date | 12/17/2013
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Provider Practice Location Address
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Address Line | 2003 COBB ST
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City | FARMVILLE
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State | VA
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Zip | 23901-2603
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Country | US
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Telephone | 434-391-6061
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Fax |
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Provider Business Mailing Address
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Address Line | 2003 COBB ST
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City | FARMVILLE
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State | VA
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Zip | 23901-2603
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Country | US
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Telephone | 434-391-6061
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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 | 0131000186
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License Number State | VA
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