Healthcare Provider Details

I. General information

NPI: 1598847915
Provider Name (Legal Business Name): JOSEPH MICHAEL KOCH A.T.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 05/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BRYANT DR
SUCCASUNNA NJ
07876-1632
US

IV. Provider business mailing address

89 SUMMIT AVE
CEDAR KNOLLS NJ
07927-1410
US

V. Phone/Fax

Practice location:
  • Phone: 973-584-1200
  • Fax: 973-584-4107
Mailing address:
  • Phone: 973-998-9398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00059400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: