Healthcare Provider Details

I. General information

NPI: 1164848115
Provider Name (Legal Business Name): MARY KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 E WILLIAMS AVE
FALLON NV
89406
US

IV. Provider business mailing address

801 E WILLIAMS AVE
FALLON NV
89406-3052
US

V. Phone/Fax

Practice location:
  • Phone: 775-867-7086
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number32648-DI-2
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: