Provider Demographics
NPI:1972617306
Name:COLE, CLARK KEVIN (PHYSICAL THERAPTIST)
Entity Type:Individual
Prefix:MR
First Name:CLARK
Middle Name:KEVIN
Last Name:COLE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:GLEN ROSE
Mailing Address - State:TX
Mailing Address - Zip Code:76043-0292
Mailing Address - Country:US
Mailing Address - Phone:254-898-2121
Mailing Address - Fax:254-898-1616
Practice Address - Street 1:1005 NE BIG BEND TRL
Practice Address - Street 2:SUITE 3
Practice Address - City:GLEN ROSE
Practice Address - State:TX
Practice Address - Zip Code:76043-4942
Practice Address - Country:US
Practice Address - Phone:254-898-2121
Practice Address - Fax:254-898-1616
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1078459225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F2877Medicare ID - Type Unspecified