Healthcare Provider Details

I. General information

NPI: 1033379029
Provider Name (Legal Business Name): MARK EDWARD KOCHKODAN LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 11/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2415 N DIXIE HWY
WILTON MANORS FL
33305-2239
US

IV. Provider business mailing address

2415 N. DIXIE HWY CHI SPA
WILTON MANORS FL
33305
US

V. Phone/Fax

Practice location:
  • Phone: 954-563-0001
  • Fax:
Mailing address:
  • Phone: 954-563-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA31242
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: