Healthcare Provider Details

I. General information

NPI: 1538975222
Provider Name (Legal Business Name): TIMOTHY KOEHLER PRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

142 CROSS LANES DR
NITRO WV
25143-1007
US

IV. Provider business mailing address

142 CROSS LANES DR
NITRO WV
25143-1007
US

V. Phone/Fax

Practice location:
  • Phone: 304-769-8484
  • Fax:
Mailing address:
  • Phone: 304-769-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number24-9168
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: