MEDICARE: MR. JAMES WALKER PENLAND JR. 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	001090	GA
2	224Z00000X	Occupational Therapy Assistant	0131000520	VA
3	224Z00000X	Occupational Therapy Assistant	2772	SC
4	224Z00000X	Occupational Therapy Assistant	1785	TN

General Provider Information

NPI Number	:	1962731950
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JAMES WALKER PENLAND JR. COTA/L

Provider Business Mailing Address
First Line	:	2414 CAMELOT DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30904-3327
Country	:	US
Telephone Number	:	706-736-0867
Fax Number	:

Provider Business Practice Location Address
First Line	:	2414 CAMELOT DR
Second Line	:
City	:	AUGUSTA
State	:	GA
Zip	:	30904-3327
Country	:	US
Telephone Number	:	706-736-0867
Fax Number	:

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

Provider Enumeration Date	:	12/22/2009
Last Update Date	:	12/22/2009

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