Healthcare Provider Details

I. General information

NPI: 1528167178
Provider Name (Legal Business Name): DIANE ELIZABETH KOCH PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 S 48TH ST STE B
SPRINGDALE AR
72762-5848
US

IV. Provider business mailing address

PO BOX 871
TONTITOWN AR
72770-0871
US

V. Phone/Fax

Practice location:
  • Phone: 479-751-3900
  • Fax:
Mailing address:
  • Phone: 479-751-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA1241
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: