Healthcare Provider Details

I. General information

NPI: 1942674171
Provider Name (Legal Business Name): BRANDI KOCH RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2015
Last Update Date: 11/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51600 HUNTINGTON RD
LA PINE OR
97739-8887
US

IV. Provider business mailing address

51600 HUNTINGTON RD
LA PINE OR
97739-8887
US

V. Phone/Fax

Practice location:
  • Phone: 541-536-3435
  • Fax:
Mailing address:
  • Phone: 541-536-3435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number201507746RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: