MEDICARE: RAYGENALD JACQUES PIERRE COTA/L

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	222Q00000X	Developmental Therapist	1438	CA

General Provider Information

NPI Number	:	1124450325
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYGENALD JACQUES PIERRE COTA/L

Provider Business Mailing Address
First Line	:	11031 JERRY LN
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-3318
Country	:	US
Telephone Number	:	619-840-6043
Fax Number	:

Provider Business Practice Location Address
First Line	:	11031 JERRY LN
Second Line	:
City	:	GARDEN GROVE
State	:	CA
Zip	:	92840-3318
Country	:	US
Telephone Number	:	619-840-6043
Fax Number	:

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

Provider Enumeration Date	:	07/30/2013
Last Update Date	:	07/30/2013

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