Provider Demographics
NPI:1790752590
Name:COLES, BRIAN LYDELL (ATC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:LYDELL
Last Name:COLES
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 BRUSHWELLMAN RD
Mailing Address - Street 2:
Mailing Address - City:OAK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84624
Mailing Address - Country:US
Mailing Address - Phone:435-864-6511
Mailing Address - Fax:435-864-0901
Practice Address - Street 1:850 BRUSHWELLMAN RD
Practice Address - Street 2:
Practice Address - City:OAK CITY
Practice Address - State:UT
Practice Address - Zip Code:84624
Practice Address - Country:US
Practice Address - Phone:435-864-6511
Practice Address - Fax:435-864-0901
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2306941-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer