Basic Information
| Provider Information | |||||||||
| NPI: | 1437616182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOFFORD | ||||||||
| FirstName: | WESTON | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NBC-HIS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8941 S 700 E STE 204 | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840702402 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7326886486 | ||||||||
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| Practice Location | |||||||||
| Address1: | 38 WEST CENTER STREET GUNNISON, UT 84634 | ||||||||
| Address2: | |||||||||
| City: | GUNNISON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846347710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8882300875 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2019 | ||||||||
| LastUpdateDate: | 02/28/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 9674125-4601 | UT | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 96374125-4601 | 01 | UT | STATE HEARING AID DISPENSER LICENSE | OTHER |