1063724938 NPI number — MRS. VICTORIA SUE HEAD COTA

Table of content: MRS. VICTORIA SUE HEAD COTA (NPI 1063724938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063724938 NPI number — MRS. VICTORIA SUE HEAD COTA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HEAD
Provider First Name:
VICTORIA
Provider Middle Name:
SUE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
COTA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOOGLAND
Provider Other First Name:
VICTORIA
Provider Other Middle Name:
SUE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063724938
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
445 GRANDVIEW CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADELL
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53001-1164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
920-254-7209
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3014 ERIE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHEBOYGAN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53081-3658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
920-459-3028
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/08/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 224Z00000X , with the licence number:  430 - 027 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)