Healthcare Provider Details

I. General information

NPI: 1811311319
Provider Name (Legal Business Name): ROBERT KOAGEDAL L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2014
Last Update Date: 02/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8591 E BELL RD STE 103
SCOTTSDALE AZ
85260-1305
US

IV. Provider business mailing address

8591 E BELL RD STE 103
SCOTTSDALE AZ
85260-1305
US

V. Phone/Fax

Practice location:
  • Phone: 480-477-7722
  • Fax:
Mailing address:
  • Phone: 480-477-7722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0327
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: