=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760021190
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLE KLOTZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2020
-----------------------------------------------------
Last Update Date | 01/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6255 N SANTA MONICA BLVD
-----------------------------------------------------
City | WHITEFISH BAY
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53217-4353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-967-8350
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2921 S MABBETT AVE
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53207-2524
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-791-0550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2251X0800X
-----------------------------------------------------
Taxonomy Name | Orthopedic Physical Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------