Provider Demographics
NPI:1952965469
Name:DISTANISLAO, COLE
Entity Type:Individual
Prefix:
First Name:COLE
Middle Name:
Last Name:DISTANISLAO
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 1:30422 VIA CANTABRIA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-5413
Mailing Address - Country:US
Mailing Address - Phone:949-973-4918
Mailing Address - Fax:
Practice Address - Street 1:30422 VIA CANTABRIA
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-5413
Practice Address - Country:US
Practice Address - Phone:949-973-4918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19950225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist