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General NPI Number Information
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NPI Number | 1952854317
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Entity Type | Individual
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Provider Name | JOHN BISTIS COTA/L
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Gender | Male
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Dates
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Enumeration Date | 08/02/2016
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Last Update Date | 08/02/2016
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Provider Practice Location Address
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Address Line | 3808 HARTNETT BLVD
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City | ISLE OF PALMS
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State | SC
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Zip | 29451-2533
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Country | US
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Telephone | 908-209-3730
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Fax |
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Provider Business Mailing Address
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Address Line | 3808 HARTNETT BLVD
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City | ISLE OF PALMS
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State | SC
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Zip | 29451-2533
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Country | US
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Telephone | 908-209-3730
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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 | 4783
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License Number State | SC
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