MEDICARE: KENNETH ROBERT KOCH DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	WI1992012	WI

General Provider Information

NPI Number	:	1386621050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH ROBERT KOCH DC

Provider Business Mailing Address
First Line	:	3449 E PLANKINTON AVE
Second Line	:
City	:	CUDAHY
State	:	WI
Zip	:	53110-1413
Country	:	US
Telephone Number	:	414-483-1060
Fax Number	:	414-483-1847

Provider Business Practice Location Address
First Line	:	3449 E PLANKINTON AVE
Second Line	:
City	:	CUDAHY
State	:	WI
Zip	:	53110-1413
Country	:	US
Telephone Number	:	414-483-1060
Fax Number	:	414-483-1847

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/23/2005
Last Update Date	:	08/15/2011

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