Provider Demographics
NPI:1295896132
Name:NORTHWEST CHILDRENS & ADOLESCENTS CLINIC
Entity type:Organization
Organization Name:NORTHWEST CHILDRENS & ADOLESCENTS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:828-265-2178
Mailing Address - Street 1:134 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5000
Mailing Address - Country:US
Mailing Address - Phone:828-265-2178
Mailing Address - Fax:828-264-1637
Practice Address - Street 1:134 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5000
Practice Address - Country:US
Practice Address - Phone:828-265-2178
Practice Address - Fax:828-264-1637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty