Healthcare Provider Details

I. General information

NPI: 1780209916
Provider Name (Legal Business Name): TROY JARED KOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 01/29/2023
Certification Date: 01/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 NEW LONDON RD
NEWARK DE
19711-7009
US

IV. Provider business mailing address

1225 FOX RD
LEESPORT PA
19533-8848
US

V. Phone/Fax

Practice location:
  • Phone: 302-453-1588
  • Fax: 302-453-9970
Mailing address:
  • Phone: 610-463-5236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT028709
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberTPT023340
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberJ10014624
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: