MEDICARE: KENNETH EUGENE CLARK 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	224Z00000X	Occupational Therapy Assistant	OTA.0000671	CO

General Provider Information

NPI Number	:	1063887834
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH EUGENE CLARK COTA

Provider Business Mailing Address
First Line	:	4885 ELDON DR S
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-4431
Country	:	US
Telephone Number	:	253-486-3624
Fax Number	:

Provider Business Practice Location Address
First Line	:	4885 ELDON DR S
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-4431
Country	:	US
Telephone Number	:	253-486-3624
Fax Number	:

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

Provider Enumeration Date	:	12/04/2015
Last Update Date	:	12/04/2015

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