Healthcare Provider Details

I. General information

NPI: 1083975262
Provider Name (Legal Business Name): RONALD MICHAEL COBLENTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2012
Last Update Date: 06/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5535 S WILLIAMSON BLVD STE 774
PORT ORANGE FL
32128-8311
US

IV. Provider business mailing address

2230 N PENNSYLVANIA ST UNIT 2
INDIANAPOLIS IN
46205-4369
US

V. Phone/Fax

Practice location:
  • Phone: 800-330-7711
  • Fax: 866-426-2811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number32001929A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: