Provider Demographics
NPI:1356188221
Name:COFFEE, DARYL
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:
Last Name:COFFEE
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 1:100 PONDEROSA ST
Mailing Address - Street 2:
Mailing Address - City:BOX ELDER
Mailing Address - State:MT
Mailing Address - Zip Code:59521
Mailing Address - Country:US
Mailing Address - Phone:406-301-0344
Mailing Address - Fax:
Practice Address - Street 1:100 PONDEROSA ST
Practice Address - Street 2:
Practice Address - City:BOX ELDER
Practice Address - State:MT
Practice Address - Zip Code:59521
Practice Address - Country:US
Practice Address - Phone:406-301-0344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver