Healthcare Provider Details

I. General information

NPI: 1558557082
Provider Name (Legal Business Name): KOCH CHIROPRACTIC LTD.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 10/03/2007
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:
Mailing address:
  • Phone: 262-784-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number111N00000X
License Number StateWI

VIII. Authorized Official

Name: DR. DENNIS A KOCH
Title or Position: OWNER
Credential: DC
Phone: 262-784-8232