Healthcare Provider Details

I. General information

NPI: 1619854197
Provider Name (Legal Business Name): VICTOR L KOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 LOCUST ST
ELDORADO IL
62930-1722
US

IV. Provider business mailing address

1308 N COURTNEY ST
MARION IL
62959-2274
US

V. Phone/Fax

Practice location:
  • Phone: 618-252-9036
  • Fax:
Mailing address:
  • Phone: 618-924-0960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: