Provider Demographics
NPI:1528538352
Name:COLE, PAKSUPIM (LMT)
Entity Type:Individual
Prefix:
First Name:PAKSUPIM
Middle Name:
Last Name:COLE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85452 HWY 11
Mailing Address - Street 2:
Mailing Address - City:MILTON FREEWATER
Mailing Address - State:OR
Mailing Address - Zip Code:97862
Mailing Address - Country:US
Mailing Address - Phone:541-861-1066
Mailing Address - Fax:
Practice Address - Street 1:618 N MAIN
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862
Practice Address - Country:US
Practice Address - Phone:541-861-1066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-05
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR24157225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist