Healthcare Provider Details

I. General information

NPI: 1104181114
Provider Name (Legal Business Name): JAMES MATT COLE II ATC/L
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 E STOTTLER DR
GILBERT AZ
85296-3629
US

IV. Provider business mailing address

1116 E STOTTLER DR
GILBERT AZ
85296-3629
US

V. Phone/Fax

Practice location:
  • Phone: 480-545-5174
  • Fax:
Mailing address:
  • Phone: 480-545-5174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0565
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: