Healthcare Provider Details

I. General information

NPI: 1790391233
Provider Name (Legal Business Name): LISA RENEE KOCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 06/24/2021
Certification Date: 06/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 SWIERKOS DR
MOUNDSVILLE WV
26041-4209
US

IV. Provider business mailing address

1062 HIGHLAND ST
FOLLANSBEE WV
26037-1416
US

V. Phone/Fax

Practice location:
  • Phone: 304-843-2306
  • Fax:
Mailing address:
  • Phone: 304-843-2306
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: