Healthcare Provider Details

I. General information

NPI: 1437616182
Provider Name (Legal Business Name): WESTON MICHAEL KOFFORD NBC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 WEST CENTER STREET GUNNISON, UT 84634
GUNNISON UT
84634-7710
US

IV. Provider business mailing address

8941 S 700 E STE 204
SANDY UT
84070-2402
US

V. Phone/Fax

Practice location:
  • Phone: 888-230-0875
  • Fax:
Mailing address:
  • Phone: 732-688-6486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number9674125-4601
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: