Provider Demographics
NPI:1063061372
Name:COLE, REGINALD EUGENE JR
Entity type:Individual
Prefix:
First Name:REGINALD
Middle Name:EUGENE
Last Name:COLE
Suffix:JR
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 1:222 E MAIN ST STE 117
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2361
Mailing Address - Country:US
Mailing Address - Phone:760-255-1496
Mailing Address - Fax:760-255-2542
Practice Address - Street 1:222 E MAIN ST STE 117
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2361
Practice Address - Country:US
Practice Address - Phone:760-255-1496
Practice Address - Fax:760-255-2542
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker