Healthcare Provider Details

I. General information

NPI: 1134423924
Provider Name (Legal Business Name): RODD KOCH P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2011
Last Update Date: 01/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 FRANCIS DR
WYNANTSKILL NY
12198-8781
US

IV. Provider business mailing address

32 FRANCIS DR
WYNANTSKILL NY
12198-8781
US

V. Phone/Fax

Practice location:
  • Phone: 518-286-9021
  • Fax:
Mailing address:
  • Phone: 518-286-9021
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number019307-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: