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General NPI Number Information
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NPI Number | 1780723510
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Entity Type | Individual
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Provider Name | MARK KOLB PTA
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Gender | Male
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Dates
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Enumeration Date | 02/06/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1525 HERBERT ST STE 103
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City | PORT ORANGE
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State | FL
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Zip | 32129-6107
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Country | US
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Telephone | 386-756-0424
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Fax | 386-756-0425
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Provider Business Mailing Address
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Address Line | 3453 COUNTRY WALK DR
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City | PORT ORANGE
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State | FL
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Zip | 32129-3156
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Country | US
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Telephone | 386-299-7427
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Fax | 386-756-0425
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | PTA 20708
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License Number State | FL
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