Healthcare Provider Details

I. General information

NPI: 1598911414
Provider Name (Legal Business Name): SANDRA KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2008
Last Update Date: 08/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

917 BEVILLE RD SUITE G
SOUTH DAYTONA FL
32119-1712
US

IV. Provider business mailing address

715 FRUITVILLE PIKE
MANHEIM PA
17545-9718
US

V. Phone/Fax

Practice location:
  • Phone: 386-756-4395
  • Fax: 866-426-2811
Mailing address:
  • Phone: 717-342-9340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT017050
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: