MEDICARE: ACTIVE NORTHWEST PODIATRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP1100X	Podiatric Clinic/Center	P0000773	WA

General Provider Information

NPI Number	:	1295156990
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ACTIVE NORTHWEST PODIATRY

Provider Business Mailing Address
First Line	:	103 E 3RD ST
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-1348
Country	:	US
Telephone Number	:	360-403-0333
Fax Number	:	360-403-0331

Provider Business Practice Location Address
First Line	:	103 E 3RD ST
Second Line	:
City	:	ARLINGTON
State	:	WA
Zip	:	98223-1348
Country	:	US
Telephone Number	:	360-403-0333
Fax Number	:	360-403-0331

Authorized Official
Title or Position	:	PODIATRIST
Name	:	DR. JAY R COCHEBA
Credential	:	DPM
Telephone Number	:	360-403-0333

Provider Enumeration Date	:	12/23/2013
Last Update Date	:	12/23/2013

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