MEDICARE: MR. BRENT EDWARD LAWLER SR. 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	314000000X	Skilled Nursing Facility	213085	TX
2	314000000X	Skilled Nursing Facility	14174	FL

General Provider Information

NPI Number	:	1780035667
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRENT EDWARD LAWLER SR. COTA

Provider Business Mailing Address
First Line	:	2508 ADAMS AVE
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-1349
Country	:	US
Telephone Number	:	727-510-8719
Fax Number	:

Provider Business Practice Location Address
First Line	:	2508 ADAMS AVE
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79761-1349
Country	:	US
Telephone Number	:	727-510-8719
Fax Number	:

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

Provider Enumeration Date	:	06/22/2016
Last Update Date	:	06/22/2016

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