Healthcare Provider Details

I. General information

NPI: 1699294462
Provider Name (Legal Business Name): ETHAN COLE BALDOCK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2017
Last Update Date: 09/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1789 KIRBY PKWY STE 3
MEMPHIS TN
38138-3657
US

IV. Provider business mailing address

1789 KIRBY PKWY STE 3
MEMPHIS TN
38138-3657
US

V. Phone/Fax

Practice location:
  • Phone: 901-759-1282
  • Fax: 901-759-1290
Mailing address:
  • Phone: 901-759-1282
  • Fax: 901-759-1290

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number6559
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: