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General NPI Number Information
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NPI Number | 1316256084
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Entity Type | Individual
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Provider Name | EDWIN GULTOM COTA
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Gender | Male
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Dates
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Enumeration Date | 09/29/2010
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Last Update Date | 09/29/2010
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Provider Practice Location Address
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Address Line | 16890 GREEN TREE BLVD
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City | VICTORVILLE
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State | CA
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Zip | 92395-5618
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Country | US
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Telephone | 760-245-5361
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Fax |
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Provider Business Mailing Address
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Address Line | 906 KENSINGTON DR
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City | REDLANDS
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State | CA
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Zip | 92374-4927
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Country | US
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Telephone | 909-255-1223
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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 | 2010
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License Number State | CA
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