Healthcare Provider Details

I. General information

NPI: 1194057893
Provider Name (Legal Business Name): GLEN WAYNE KOCH LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2552 S DISCOVERY RD
PORT TOWNSEND WA
98368-8216
US

IV. Provider business mailing address

2552 S DISCOVERY RD
PORT TOWNSEND WA
98368-8216
US

V. Phone/Fax

Practice location:
  • Phone: 360-316-9093
  • Fax:
Mailing address:
  • Phone: 360-316-9093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60133166
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: