Provider Demographics
NPI:1720470651
Name:KOCH, KYLE R (BC-HIS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:R
Last Name:KOCH
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6612 E MILL PLAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98661-7458
Mailing Address - Country:US
Mailing Address - Phone:360-695-8742
Mailing Address - Fax:360-696-6721
Practice Address - Street 1:6612 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7458
Practice Address - Country:US
Practice Address - Phone:360-695-8742
Practice Address - Fax:360-696-6721
Is Sole Proprietor?:No
Enumeration Date:2015-03-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAHA60511045237700000X
ORHAS-P-10130363237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist