Healthcare Provider Details

I. General information

NPI: 1275205940
Provider Name (Legal Business Name): COLE THOMAS DEMOULPIED CORPSMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2587 OLD QUARRY RD UNIT 2232
SAN DIEGO CA
92108
US

IV. Provider business mailing address

2587 OLD QUARRY RD UNIT 2232
SAN DIEGO CA
92108
US

V. Phone/Fax

Practice location:
  • Phone: 231-632-4574
  • Fax:
Mailing address:
  • Phone: 231-632-4574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: