Provider Demographics
NPI:1891842878
Name:EAMES, MARK ALLEN (COTA)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:EAMES
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
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Mailing Address - Street 1:9402 S MARSH CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MCCAMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83250-1695
Mailing Address - Country:US
Mailing Address - Phone:208-254-9942
Mailing Address - Fax:
Practice Address - Street 1:510 E 17TH ST
Practice Address - Street 2:SUITE 400
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6154
Practice Address - Country:US
Practice Address - Phone:208-589-0807
Practice Address - Fax:208-542-9577
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOTA-100224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant