Healthcare Provider Details

I. General information

NPI: 1134883861
Provider Name (Legal Business Name): MARK KOCH DC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2021
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
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 Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. MARK JAMES KOCH
Title or Position: OWNER DOCTOR
Credential: DC
Phone: 262-784-8232