Healthcare Provider Details

I. General information

NPI: 1770843906
Provider Name (Legal Business Name): KOCH AUDIOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2012
Last Update Date: 05/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N WESTERN AVE
MARION IN
46952-2505
US

IV. Provider business mailing address

915 N WESTERN AVE
MARION IN
46952-2505
US

V. Phone/Fax

Practice location:
  • Phone: 765-664-3470
  • Fax:
Mailing address:
  • Phone: 765-664-3470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number23002390A
License Number StateIN

VIII. Authorized Official

Name: DR. ANDREA STOUT KOCH
Title or Position: OWNER
Credential: AU.D.
Phone: 317-464-9067