Healthcare Provider Details

I. General information

NPI: 1871991588
Provider Name (Legal Business Name): DYLAN COLT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2014
Last Update Date: 12/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1827 ATLANTA AVE
RIVERSIDE CA
92507-7419
US

IV. Provider business mailing address

1827 ATLANTA AVE
RIVERSIDE CA
92507-7419
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-8000
  • Fax:
Mailing address:
  • Phone: 951-955-8000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: