Healthcare Provider Details

I. General information

NPI: 1295896132
Provider Name (Legal Business Name): NORTHWEST CHILDRENS & ADOLESCENTS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 DOCTORS DR
BOONE NC
28607-5000
US

IV. Provider business mailing address

134 DOCTORS DR
BOONE NC
28607-5000
US

V. Phone/Fax

Practice location:
  • Phone: 828-265-2178
  • Fax: 828-264-1637
Mailing address:
  • Phone: 828-265-2178
  • Fax: 828-264-1637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: DR. EDITH KOCIS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 828-265-2178