Healthcare Provider Details

I. General information

NPI: 1922871334
Provider Name (Legal Business Name): KOCH CHIROPRACTIC AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 11/07/2023
Certification Date: 11/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N430 WOOD DUCK DR
FREMONT WI
54940-8855
US

IV. Provider business mailing address

1990 GODFREY DR
WAUPACA WI
54981-7908
US

V. Phone/Fax

Practice location:
  • Phone: 715-256-9616
  • Fax: 715-256-9618
Mailing address:
  • Phone: 715-256-9616
  • Fax: 715-256-9618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER DORAY
Title or Position: BILLING/ACCOUNTS
Credential:
Phone: 715-256-9616