Healthcare Provider Details

I. General information

NPI: 1861454795
Provider Name (Legal Business Name): CHAD KOCH ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 MAIN ST NW
BOURBONNAIS IL
60914-2383
US

IV. Provider business mailing address

336 S PRAIRIE AVE
BRADLEY IL
60915-2139
US

V. Phone/Fax

Practice location:
  • Phone: 815-936-1855
  • Fax: 815-936-6097
Mailing address:
  • Phone: 815-802-0512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: