MEDICARE: COTTAGE LANDING, LLC

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	305S00000X	Point of Service

General Provider Information

NPI Number	:	1801092556
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COTTAGE LANDING, LLC

Provider Business Mailing Address
First Line	:	78 CENTENNIAL LOOP
Second Line	:
City	:	EUGENE
State	:	OR
Zip	:	97401-7900
Country	:	US
Telephone Number	:	541-747-3373
Fax Number	:	541-747-0673

Provider Business Practice Location Address
First Line	:	150 COTTAGE LN
Second Line	:
City	:	CARROLLTON
State	:	GA
Zip	:	30117-6200
Country	:	US
Telephone Number	:	770-830-8857
Fax Number	:	770-214-0692

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MR. JOHN HOLTZ
Credential	:
Telephone Number	:	541-747-3373

Provider Enumeration Date	:	06/21/2007
Last Update Date	:	05/13/2008

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