Provider Demographics
NPI:1871608695
Name:COLE DIAGNOSTICS, INC
Entity type:Organization
Organization Name:COLE DIAGNOSTICS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-472-1082
Mailing Address - Street 1:7988 W. MARIGOLD ST.
Mailing Address - Street 2:STE. 150
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714
Mailing Address - Country:US
Mailing Address - Phone:208-472-1082
Mailing Address - Fax:208-472-1078
Practice Address - Street 1:7988 W. MARIGOLD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714
Practice Address - Country:US
Practice Address - Phone:208-229-0990
Practice Address - Fax:800-838-5913
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID13D1020051291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
1400759Medicare ID - Type Unspecified
G84249Medicare UPIN