Healthcare Provider Details

I. General information

NPI: 1467943738
Provider Name (Legal Business Name): TANNER ALLEN KOCH LAT/ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 BIRDIE LN
BRYANT AR
72022-6740
US

IV. Provider business mailing address

2810 BIRDIE LN
BRYANT AR
72022-6740
US

V. Phone/Fax

Practice location:
  • Phone: 214-476-2455
  • Fax:
Mailing address:
  • Phone: 214-476-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: