Healthcare Provider Details

I. General information

NPI: 1407173719
Provider Name (Legal Business Name): KATHLEEN J KOCH RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2010
Last Update Date: 04/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 4TH ST SW
MASON CITY IA
50401-2800
US

IV. Provider business mailing address

1000 4TH ST SW
MASON CITY IA
50401-2800
US

V. Phone/Fax

Practice location:
  • Phone: 641-422-7000
  • Fax: 641-422-6433
Mailing address:
  • Phone: 641-422-7000
  • Fax: 641-422-6433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number01243
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: