Healthcare Provider Details

I. General information

NPI: 1720470651
Provider Name (Legal Business Name): KYLE R. KOCH BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 03/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6612 E MILL PLAIN BLVD
VANCOUVER WA
98661-7458
US

IV. Provider business mailing address

6612 E MILL PLAIN BLVD
VANCOUVER WA
98661-7458
US

V. Phone/Fax

Practice location:
  • Phone: 360-695-8742
  • Fax: 360-696-6721
Mailing address:
  • Phone: 360-695-8742
  • Fax: 360-696-6721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA60511045
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHAS-P-10130363
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: