Provider Demographics
NPI:1306406848
Name:GODTLAND, COLE JOSEPH
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:JOSEPH
Last Name:GODTLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3690 SHALE CT
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-1247
Mailing Address - Country:US
Mailing Address - Phone:972-897-9469
Mailing Address - Fax:
Practice Address - Street 1:3690 SHALE CT
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-1247
Practice Address - Country:US
Practice Address - Phone:972-897-9469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-17
Last Update Date:2019-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV999999999999999999993747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty