MEDICARE: REBECCA HIER DAVIS 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	172V00000X	Community Health Worker	OTA1633	CA

General Provider Information

NPI Number	:	1356678437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA HIER DAVIS COTA

Provider Business Mailing Address
First Line	:	7025 MONTANA AVE
Second Line	:
City	:	FONTANA
State	:	CA
Zip	:	92336-0814
Country	:	US
Telephone Number	:	909-429-6185
Fax Number	:

Provider Business Practice Location Address
First Line	:	4600 PEDLEY AVE
Second Line	:
City	:	NORCO
State	:	CA
Zip	:	92860-1533
Country	:	US
Telephone Number	:	951-736-3245
Fax Number	:

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

Provider Enumeration Date	:	11/10/2009
Last Update Date	:	11/10/2009

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