1366048274 NPI number — KACEY KOEHLER

Table of content: KACEY KOEHLER (NPI 1366048274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366048274 NPI number — KACEY KOEHLER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KOEHLER
Provider First Name:
KACEY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
PAUKOVICH
Provider Other First Name:
KACEY
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366048274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 NOBLE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOOSTER
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44691-5353
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-264-3232
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2000 NOBLE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOOSTER
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44691-5353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-264-3232
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/07/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)