Healthcare Provider Details

I. General information

NPI: 1669613055
Provider Name (Legal Business Name): ERICA COLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2009
Last Update Date: 03/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 BEVILLE RD STE. G
SOUTH DAYTONA FL
32119-1712
US

IV. Provider business mailing address

79 FULTON RD
LISBON NY
13658-3185
US

V. Phone/Fax

Practice location:
  • Phone: 386-756-4395
  • Fax: 866-426-2811
Mailing address:
  • Phone: 386-756-4395
  • Fax: 866-426-2811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number030878
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number18541
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: