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General NPI Number Information
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NPI Number | 1295156990
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Entity Type | Organization
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Legal Business Name | ACTIVE NORTHWEST PODIATRY
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Dates
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Enumeration Date | 12/23/2013
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Last Update Date | 12/23/2013
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Provider Practice Location Address
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Address Line | 103 E 3RD ST
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City | ARLINGTON
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State | WA
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Zip | 98223-1348
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Country | US
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Telephone | 360-403-0333
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Fax | 360-403-0331
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Provider Business Mailing Address
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Address Line | 103 E 3RD ST
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City | ARLINGTON
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State | WA
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Zip | 98223-1348
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Country | US
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Telephone | 360-403-0333
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Fax | 360-403-0331
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Authorized Official
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Title or Position | PODIATRIST
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Name | DR. JAY R COCHEBA
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Credential | DPM
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Telephone | 360-403-0333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP1100X
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Taxonomy Name | Podiatric Clinic/Center
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License Number | P0000773
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License Number State | WA
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