MEDICARE: RUSTEN RAY GODWIN 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	216247	TX

General Provider Information

NPI Number	:	1144986175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSTEN RAY GODWIN COTA

Provider Business Mailing Address
First Line	:	4302 ROSS AVE APT 3041
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-5114
Country	:	US
Telephone Number	:	501-339-6193
Fax Number	:

Provider Business Practice Location Address
First Line	:	4302 ROSS AVE APT 3041
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75204-5114
Country	:	US
Telephone Number	:	501-339-6193
Fax Number	:

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

Provider Enumeration Date	:	11/15/2021
Last Update Date	:	11/15/2021

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