Provider Demographics
NPI:1518592732
Name:BAMFORD, COBY A (DTR)
Entity Type:Individual
Prefix:
First Name:COBY
Middle Name:A
Last Name:BAMFORD
Suffix:
Gender:F
Credentials:DTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 PULASKI AVE
Mailing Address - Street 2:
Mailing Address - City:COAL TOWNSHIP
Mailing Address - State:PA
Mailing Address - Zip Code:17866-4056
Mailing Address - Country:US
Mailing Address - Phone:570-809-1588
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-9800
Practice Address - Country:US
Practice Address - Phone:570-214-1077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-09
Last Update Date:2020-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, Registered