Provider Demographics
NPI:1437616182
Name:KOFFORD, WESTON MICHAEL (NBC-HIS)
Entity Type:Individual
Prefix:MR
First Name:WESTON
Middle Name:MICHAEL
Last Name:KOFFORD
Suffix:
Gender:M
Credentials:NBC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8941 S 700 E STE 204
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-2402
Mailing Address - Country:US
Mailing Address - Phone:732-688-6486
Mailing Address - Fax:
Practice Address - Street 1:38 WEST CENTER STREET GUNNISON, UT 84634
Practice Address - Street 2:
Practice Address - City:GUNNISON
Practice Address - State:UT
Practice Address - Zip Code:84634-7710
Practice Address - Country:US
Practice Address - Phone:888-230-0875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-28
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9674125-4601237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT96374125-4601OtherSTATE HEARING AID DISPENSER LICENSE