Provider Demographics
NPI:1518209733
Name:COLE, DEANGELO DUBOIS (BST)
Entity Type:Individual
Prefix:MR
First Name:DEANGELO
Middle Name:DUBOIS
Last Name:COLE
Suffix:
Gender:M
Credentials:BST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7577 BEVERLY HILLS DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89147-4981
Mailing Address - Country:US
Mailing Address - Phone:314-494-1376
Mailing Address - Fax:
Practice Address - Street 1:5175 CAMINO AL NORTE
Practice Address - Street 2:SUITE 100
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-2407
Practice Address - Country:US
Practice Address - Phone:702-648-3913
Practice Address - Fax:702-868-8357
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner