Healthcare Provider Details

I. General information

NPI: 1467846857
Provider Name (Legal Business Name): SKYE KOCH RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 03/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 5TH ST N
NEW ULM MN
56073-1514
US

IV. Provider business mailing address

1324 5TH ST N
NEW ULM MN
56073-1514
US

V. Phone/Fax

Practice location:
  • Phone: 507-217-5639
  • Fax: 507-233-1627
Mailing address:
  • Phone: 507-217-5639
  • Fax: 507-233-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3021
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: