Healthcare Provider Details

I. General information

NPI: 1841518545
Provider Name (Legal Business Name): HAZEL YVETTE KOCH D.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2010
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 WATERMAN STREET
PROVIDENCE RI
02906
US

IV. Provider business mailing address

148 WATERMAN STREET
PROVIDENCE RI
02906
US

V. Phone/Fax

Practice location:
  • Phone: 401-864-5453
  • Fax:
Mailing address:
  • Phone: 401-864-5453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberDA00350
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: