Provider Demographics
NPI:1932113982
Name:COLE, TRACY DAVID (DC)
Entity Type:Individual
Prefix:DR
First Name:TRACY
Middle Name:DAVID
Last Name:COLE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1072
Mailing Address - Street 2:
Mailing Address - City:CRESCENT CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95531-1072
Mailing Address - Country:US
Mailing Address - Phone:707-464-2921
Mailing Address - Fax:707-464-2131
Practice Address - Street 1:785 E WASHINGTON BLVD
Practice Address - Street 2:STE 5
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8372
Practice Address - Country:US
Practice Address - Phone:707-464-2921
Practice Address - Fax:707-464-2131
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20865111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0208650Medicaid
CADC0208650Medicare ID - Type Unspecified
CADC0208650Medicaid