=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477201853
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY COLES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2022
-----------------------------------------------------
Last Update Date | 03/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2423 N NEWKIRK ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19132-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-686-8342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2423 N NEWKIRK ST
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19132-3508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-686-8342
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | 10048251
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------