Healthcare Provider Details

I. General information

NPI: 1265092928
Provider Name (Legal Business Name): KOBERNIK OSTEOPATHY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10503 GUTHRIE RD
ANDERSON ISLAND WA
98303-9753
US

IV. Provider business mailing address

10503 GUTHRIE RD
ANDERSON ISLAND WA
98303-9753
US

V. Phone/Fax

Practice location:
  • Phone: 253-225-7248
  • Fax:
Mailing address:
  • Phone: 253-225-7248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. BETH DAWN KOBERNIK
Title or Position: ADMINISTRATOR
Credential:
Phone: 253-225-7248