Healthcare Provider Details

I. General information

NPI: 1487732897
Provider Name (Legal Business Name): THOMAS COLE ELU PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1680 SW SAINT LUCIE WEST BLVD
PORT ST LUCIE FL
34986-1927
US

IV. Provider business mailing address

565 SW NORTH QUICK CIR
PORT SAINT LUCIE FL
34953-6086
US

V. Phone/Fax

Practice location:
  • Phone: 772-878-3322
  • Fax:
Mailing address:
  • Phone: 772-873-0741
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA14058
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: