1972617306 NPI number — MR. CLARK KEVIN COLE PHYSICAL THERAPTIST

Table of content: MR. CLARK KEVIN COLE PHYSICAL THERAPTIST (NPI 1972617306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972617306 NPI number — MR. CLARK KEVIN COLE PHYSICAL THERAPTIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLE
Provider First Name:
CLARK
Provider Middle Name:
KEVIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PHYSICAL THERAPTIST
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:
1972617306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 292
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLEN ROSE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76043-0292
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
254-898-2121
Provider Business Mailing Address Fax Number:
254-898-1616

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 NE BIG BEND TRL
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
GLEN ROSE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76043-4942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
254-898-2121
Provider Business Practice Location Address Fax Number:
254-898-1616
Provider Enumeration Date:
08/19/2006

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: 225100000X , with the licence number:  1078459 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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