Healthcare Provider Details

I. General information

NPI: 1699900381
Provider Name (Legal Business Name): CAROL ANN KOCH D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2009
Last Update Date: 05/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 DEVON DR
SAN RAFAEL CA
94903-3708
US

IV. Provider business mailing address

208 DEVON DR
SAN RAFAEL CA
94903-3708
US

V. Phone/Fax

Practice location:
  • Phone: 415-491-0636
  • Fax: 415-491-0636
Mailing address:
  • Phone: 415-491-0636
  • Fax: 415-491-0636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number11630
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: