Provider Demographics
NPI:1477833580
Name:GUSTAMANTES, FRANK M (COTA)
Entity Type:Individual
Prefix:
First Name:FRANK
Middle Name:M
Last Name:GUSTAMANTES
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 1:304 N RICHARDSON AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-4639
Mailing Address - Country:US
Mailing Address - Phone:575-578-0069
Mailing Address - Fax:575-578-0124
Practice Address - Street 1:304 N RICHARDSON AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-4639
Practice Address - Country:US
Practice Address - Phone:575-578-0069
Practice Address - Fax:575-578-0124
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2126224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant