1700483278 NPI number — NICHOLAS N KOCH DPT

Table of content: NICHOLAS N KOCH DPT (NPI 1700483278)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700483278 NPI number — NICHOLAS N KOCH DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOCH
Provider First Name:
NICHOLAS
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1700483278
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2002 W SUNSET DR STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVERTON
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82501-2285
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-856-7021
Provider Business Mailing Address Fax Number:
307-856-5546

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8168 HIGHWAY 789
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANDER
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82520-2953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-332-5240
Provider Business Practice Location Address Fax Number:
307-332-5241
Provider Enumeration Date:
10/07/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  2013 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)