Healthcare Provider Details

I. General information

NPI: 1144454802
Provider Name (Legal Business Name): WILLIAM ROBERT COLE IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2009
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 MDG EDWARDS AFB CA
EDWARDS AFB CA
93524-0001
US

IV. Provider business mailing address

42430 56TH ST W
QUARTZ HILL CA
93536-4450
US

V. Phone/Fax

Practice location:
  • Phone: 661-277-3132
  • Fax:
Mailing address:
  • Phone: 661-839-5673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: