Provider Demographics
NPI:1245697895
Name:NIETO QUINTERO, JUAN CARLOS (COTA)
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:CARLOS
Last Name:NIETO QUINTERO
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 1:2813 OAK ST
Mailing Address - Street 2:APT 2
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32205-4206
Mailing Address - Country:US
Mailing Address - Phone:904-803-5766
Mailing Address - Fax:
Practice Address - Street 1:2813 OAK ST
Practice Address - Street 2:APT 2
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32205-4206
Practice Address - Country:US
Practice Address - Phone:904-803-5766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13979224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant