Healthcare Provider Details

I. General information

NPI: 1396019766
Provider Name (Legal Business Name): MARKUS KOCH LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21390 WATERLOO RD
CHLESEA MI
48118
US

IV. Provider business mailing address

21390 WATERLOO RD
CHELSEA MI
48118-9122
US

V. Phone/Fax

Practice location:
  • Phone: 734-660-0898
  • Fax: 866-816-1311
Mailing address:
  • Phone: 734-660-0898
  • Fax: 866-816-1311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License Number7501000733
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: