Healthcare Provider Details

I. General information

NPI: 1134687296
Provider Name (Legal Business Name): BRANDI KOCH RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 03/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9825 N 95TH ST STE 101
SCOTTSDALE AZ
85258-4590
US

IV. Provider business mailing address

3716 W DENALI DR
ANTHEM AZ
85086-8026
US

V. Phone/Fax

Practice location:
  • Phone: 480-941-4247
  • Fax:
Mailing address:
  • Phone: 214-250-1432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number895934
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: