Healthcare Provider Details

I. General information

NPI: 1801253810
Provider Name (Legal Business Name): PEARL COLESHILL ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2016
Last Update Date: 01/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3121 UNIVERSITY DRIVE E. SUITE 100
BRYAN TX
77802
US

IV. Provider business mailing address

4607 BROMPTON LN
BRYAN TX
77802-5611
US

V. Phone/Fax

Practice location:
  • Phone: 979-776-0169
  • Fax: 979-776-1372
Mailing address:
  • Phone: 803-325-5429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT6404
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: