Healthcare Provider Details

I. General information

NPI: 1417554288
Provider Name (Legal Business Name): KENNETH DONNELL COLES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2020
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 W SHERWOOD AVE
HAMPTON VA
23663-1403
US

IV. Provider business mailing address

44 W SHERWOOD AVE
HAMPTON VA
23663-1403
US

V. Phone/Fax

Practice location:
  • Phone: 757-775-3732
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: