Basic Information
| Provider Information | |||||||||
| NPI: | 1437369469 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COKE | ||||||||
| FirstName: | CARILYN | ||||||||
| MiddleName: | FAY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 411 W KING ST | ||||||||
| Address2: | |||||||||
| City: | COULTERVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 622371529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6187581188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 900 N WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | DU QUOIN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 628321230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6185422146 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | IL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.