1871211748 NPI number — ETHAN CONALL COLE IDC

Table of content: ETHAN CONALL COLE IDC (NPI 1871211748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871211748 NPI number — ETHAN CONALL COLE IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLE
Provider First Name:
ETHAN
Provider Middle Name:
CONALL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871211748
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
USS FRANK CABLE
Provider Second Line Business Mailing Address:
UNIT 100105 BOX 216 FPO, AE 96567-0502
Provider Business Mailing Address City Name:
AGUANA
Provider Business Mailing Address State Name:
GU
Provider Business Mailing Address Postal Code:
96567
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
717-601-4053
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USS FRANK CABLE
Provider Second Line Business Practice Location Address:
UNIT 100105
Provider Business Practice Location Address City Name:
AGUANA
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
717-601-4053
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/17/2022

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: 390200000X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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