Provider Demographics
NPI:1811133036
Name:COCHRAN, A. DALE
Entity type:Individual
Prefix:
First Name:A.
Middle Name:DALE
Last Name:COCHRAN
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 1:205 GOLDENEYE CT
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-5034
Mailing Address - Country:US
Mailing Address - Phone:636-387-0081
Mailing Address - Fax:
Practice Address - Street 1:205 GOLDENEYE CT
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-5034
Practice Address - Country:US
Practice Address - Phone:636-387-0081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-17
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO6754-11125177F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes177F00000XOther Service ProvidersLodgingGroup - Single Specialty