Healthcare Provider Details

I. General information

NPI: 1790439230
Provider Name (Legal Business Name): PEYTON KOCH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2022
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 WILLAMETTE ST STE F
EUGENE OR
97405-3295
US

IV. Provider business mailing address

2320 HAWKINS LN
EUGENE OR
97405-1361
US

V. Phone/Fax

Practice location:
  • Phone: 714-334-4071
  • Fax:
Mailing address:
  • Phone: 714-334-4071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number26784
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: