Healthcare Provider Details

I. General information

NPI: 1699828251
Provider Name (Legal Business Name): MARK JAMES KOCH D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 06/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 LEGION DR
ELM GROVE WI
53122-2202
US

IV. Provider business mailing address

1055 LEGION DR
ELM GROVE WI
53122-2202
US

V. Phone/Fax

Practice location:
  • Phone: 262-784-8232
  • Fax: 262-784-4139
Mailing address:
  • Phone: 262-784-8232
  • Fax: 262-784-4139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3460
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: