Provider Demographics
NPI:1245913821
Name:KOEHL, BRADY MICHAEL
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:MICHAEL
Last Name:KOEHL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5066 N NEARGLEN AVE
Mailing Address - Street 2:
Mailing Address - City:COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91724-1046
Mailing Address - Country:US
Mailing Address - Phone:281-917-0181
Mailing Address - Fax:
Practice Address - Street 1:10210 ORR AND DAY RD
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-3581
Practice Address - Country:US
Practice Address - Phone:562-348-0083
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-09
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program