Provider Demographics
NPI:1871556811
Name:COLE, KENNETH A (PT)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:A
Last Name:COLE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:
Practice Address - Street 1:17800 TALBOT RD S
Practice Address - Street 2:SUITE D
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5740
Practice Address - Country:US
Practice Address - Phone:425-277-9096
Practice Address - Fax:425-277-1206
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008275225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8332868Medicaid
WAG8868583Medicare PIN
WAG8905384Medicare PIN
WA8332868Medicaid
WAGAB38972Medicare PIN