Healthcare Provider Details

I. General information

NPI: 1124496336
Provider Name (Legal Business Name): WILLIAM COLE DESIGNATED MANAGER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2015
Last Update Date: 09/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 MULLANPHY ST
SAINT LOUIS MO
63106-3114
US

IV. Provider business mailing address

1451 MULLANPHY ST
SAINT LOUIS MO
63106-3114
US

V. Phone/Fax

Practice location:
  • Phone: 314-409-1686
  • Fax:
Mailing address:
  • Phone: 314-409-1686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: