Provider Demographics
NPI:1386123230
Name:ACOSTA, JOSE (COTA)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:ACOSTA
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 N FRESNO ST APT 143
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-5505
Mailing Address - Country:US
Mailing Address - Phone:305-746-1613
Mailing Address - Fax:
Practice Address - Street 1:650 W ALLUVIAL AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6716
Practice Address - Country:US
Practice Address - Phone:559-323-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-11
Last Update Date:2018-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4436224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy AssistantGroup - Single Specialty