Healthcare Provider Details

I. General information

NPI: 1245256148
Provider Name (Legal Business Name): DIANE KOCH PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 HOSPITAL RD SUITE 606
NEWPORT BEACH CA
92663-3509
US

IV. Provider business mailing address

351 HOSPITAL RD SUITE 606
NEWPORT BEACH CA
92663-3509
US

V. Phone/Fax

Practice location:
  • Phone: 949-650-3870
  • Fax: 949-650-2544
Mailing address:
  • Phone: 949-650-3870
  • Fax: 949-650-2544

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT9997
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: