=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184020794
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLE PEDIATRIC THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/09/2014
-----------------------------------------------------
Last Update Date | 11/09/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 702 HIGH MEADOW RANCH DR
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77355-2760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-542-8833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 702 HIGH MEADOW RANCH DR
-----------------------------------------------------
City | MAGNOLIA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77355-2760
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 713-542-8833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF REHABILITATION
-----------------------------------------------------
Name | JUSTIN COLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 281-379-4373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0700X
-----------------------------------------------------
Taxonomy Name | Hearing and Speech Clinic/Center
-----------------------------------------------------
License Number | 110189
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------