Provider Demographics
NPI:1366435414
Name:COLE, MARK E IV (ATC,LAT,CSCS)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:E
Last Name:COLE
Suffix:IV
Gender:M
Credentials:ATC,LAT,CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E SAINT PAUL AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-5907
Mailing Address - Country:US
Mailing Address - Phone:414-223-2727
Mailing Address - Fax:414-223-2724
Practice Address - Street 1:625 E SAINT PAUL AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53202-5907
Practice Address - Country:US
Practice Address - Phone:414-223-2727
Practice Address - Fax:414-223-2724
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2250392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer