MEDICARE: JUSTIN EUTSLER 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	32002131A	IN

General Provider Information

NPI Number	:	1992174098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN EUTSLER COTA

Provider Business Mailing Address
First Line	:	4814 W WALLEN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-9407
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4814 W WALLEN RD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-9407
Country	:	US
Telephone Number	:	260-609-3753
Fax Number	:

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

Provider Enumeration Date	:	09/18/2015
Last Update Date	:	09/18/2015

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