Provider Demographics
NPI:1598015463
Name:COLE, PHELAN (DPT)
Entity Type:Individual
Prefix:
First Name:PHELAN
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6180 BROCKTON AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2228
Mailing Address - Country:US
Mailing Address - Phone:951-781-6653
Mailing Address - Fax:951-275-0159
Practice Address - Street 1:6180 BROCKTON AVE
Practice Address - Street 2:STE 101
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2228
Practice Address - Country:US
Practice Address - Phone:951-781-6653
Practice Address - Fax:951-275-0159
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39416225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist