MEDICARE: FANKIE THURSTON COTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	205027	TX

General Provider Information

NPI Number	:	1043403843
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FANKIE THURSTON COTA

Provider Business Mailing Address
First Line	:	5100 N KINGS HWY LOT 48
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-1069
Country	:	US
Telephone Number	:	903-831-3198
Fax Number	:

Provider Business Practice Location Address
First Line	:	5100 N KINGS HWY LOT 48
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-1069
Country	:	US
Telephone Number	:	903-831-3198
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2007
Last Update Date	:	08/24/2007

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Directions to “ FANKIE THURSTON COTA” Practice Location

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