Provider Demographics
NPI:1871991588
Name:COLT, DYLAN
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:COLT
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 1:1827 ATLANTA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-7419
Mailing Address - Country:US
Mailing Address - Phone:951-955-8000
Mailing Address - Fax:
Practice Address - Street 1:1827 ATLANTA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-7419
Practice Address - Country:US
Practice Address - Phone:951-955-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-11
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist