Healthcare Provider Details

I. General information

NPI: 1811133036
Provider Name (Legal Business Name): A. DALE COCHRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 GOLDENEYE CT
SAINT PETERS MO
63376-5034
US

IV. Provider business mailing address

205 GOLDENEYE CT
SAINT PETERS MO
63376-5034
US

V. Phone/Fax

Practice location:
  • Phone: 636-387-0081
  • Fax:
Mailing address:
  • Phone: 636-387-0081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number6754-11125
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: