Provider Demographics
NPI:1306210877
Name:COLES HEALTHCARE SERVICES INC
Entity Type:Organization
Organization Name:COLES HEALTHCARE SERVICES INC
Other - Org Name:TRADITIONAL MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:COLES
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:954-593-5524
Mailing Address - Street 1:3898 W COMMERCIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33309-3326
Mailing Address - Country:US
Mailing Address - Phone:754-444-8826
Mailing Address - Fax:954-856-2921
Practice Address - Street 1:3898 W COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33309-3326
Practice Address - Country:US
Practice Address - Phone:754-444-8826
Practice Address - Fax:954-856-2921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-21
Last Update Date:2015-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty