Healthcare Provider Details

I. General information

NPI: 1225305089
Provider Name (Legal Business Name): BRANDON KOCH CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2011
Last Update Date: 11/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 S ALBION ST SUITE 425
DENVER CO
80222-4008
US

IV. Provider business mailing address

601 E GRUNDY ST APT H
TULLAHOMA TN
37388-3743
US

V. Phone/Fax

Practice location:
  • Phone: 720-214-2549
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number2050
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: