Basic Information
| Provider Information | |||||||||
| NPI: | 1538278189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOOS | ||||||||
| FirstName: | TODD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 DICKERSON BLVD STE I | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281102884 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042836712 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1730 DICKERSON BLVD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | MONROE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281102885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042836700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 07/29/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 9417 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 9417 | 01 | NC | LICENSE # | OTHER |