Provider Demographics
NPI:1669888244
Name:COLE, KENNETH
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:COLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:938 W HILLIARD LN
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97404-3014
Mailing Address - Country:US
Mailing Address - Phone:541-735-3643
Mailing Address - Fax:541-735-3645
Practice Address - Street 1:938 W HILLIARD LN
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97404-3014
Practice Address - Country:US
Practice Address - Phone:541-735-3643
Practice Address - Fax:541-735-3645
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-03
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR519093253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency