Healthcare Provider Details

I. General information

NPI: 1154860013
Provider Name (Legal Business Name): MARIA KOFAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2017
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SOUTH 7650 EAST 1010
CROW AGENCY MT
59022
US

IV. Provider business mailing address

SOUTH 7650 EAST, 1010
CROW AGENCY MT
59022
US

V. Phone/Fax

Practice location:
  • Phone: 406-638-3442
  • Fax:
Mailing address:
  • Phone: 406-638-3442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberMED-NUTR-LIC-52903
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: