MEDICARE: MRS. REBBECCA ANN GWALTNEY 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	247200000X	Other Technician	057.002498	IL

General Provider Information

NPI Number	:	1235499120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. REBBECCA ANN GWALTNEY COTA/L

Provider Business Mailing Address
First Line	:	2352 STATE HIGHWAY 78 N
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-6227
Country	:	US
Telephone Number	:	217-473-5913
Fax Number	:

Provider Business Practice Location Address
First Line	:	2352 STATE HIGHWAY 78 N
Second Line	:
City	:	JACKSONVILLE
State	:	IL
Zip	:	62650-6227
Country	:	US
Telephone Number	:	217-473-5913
Fax Number	:

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

Provider Enumeration Date	:	05/24/2012
Last Update Date	:	05/24/2012

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