Healthcare Provider Details

I. General information

NPI: 1003363284
Provider Name (Legal Business Name): MICHAEL KOCH CADCII, BSCJA, SAP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 09/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 BEECH AVE STE B
CARLSBAD CA
92008-1657
US

IV. Provider business mailing address

580 BEECH AVE STE B
CARLSBAD CA
92008-1657
US

V. Phone/Fax

Practice location:
  • Phone: 760-224-6631
  • Fax:
Mailing address:
  • Phone: 760-224-6631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA022080216
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: