Provider Demographics
NPI:1619451275
Name:KOKKONEN P M AND R PC
Entity type:Organization
Organization Name:KOKKONEN P M AND R PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:JUHANI
Authorized Official - Last Name:KOKKONEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:801-473-2261
Mailing Address - Street 1:2431 N HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-8201
Mailing Address - Country:US
Mailing Address - Phone:801-473-2261
Mailing Address - Fax:
Practice Address - Street 1:3372 E JENALAN
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7787
Practice Address - Country:US
Practice Address - Phone:801-473-2261
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDO-1190OtherMEDICAL LICENSE