MEDICARE: SEVERO PEREZ III 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	209896	TX

General Provider Information

NPI Number	:	1780241299
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SEVERO PEREZ III COTA

Provider Business Mailing Address
First Line	:	1634 COUNTRY HLS
Second Line	:
City	:	WAXAHACHIE
State	:	TX
Zip	:	75165-6172
Country	:	US
Telephone Number	:	817-991-7812
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 HAPPY LN
Second Line	:
City	:	HILLSBORO
State	:	TX
Zip	:	76645-2624
Country	:	US
Telephone Number	:	254-583-8482
Fax Number	:

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

Provider Enumeration Date	:	05/21/2019
Last Update Date	:	05/21/2019

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