MEDICARE: JORGE LUIS MAYORGA 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	224Z00000X	Occupational Therapy Assistant	OTA11099	FL

General Provider Information

NPI Number	:	1417256454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORGE LUIS MAYORGA COTA/L

Provider Business Mailing Address
First Line	:	10633 HAMMOCKS BLVD
Second Line	:	APT 1028
City	:	MIAMI
State	:	FL
Zip	:	33196-4719
Country	:	US
Telephone Number	:	786-360-2110
Fax Number	:

Provider Business Practice Location Address
First Line	:	9863 SW 184TH ST
Second Line	:
City	:	PALMETTO BAY
State	:	FL
Zip	:	33157-6934
Country	:	US
Telephone Number	:	305-252-6454
Fax Number	:

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

Provider Enumeration Date	:	03/16/2011
Last Update Date	:	03/16/2011

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