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General NPI Number Information
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NPI Number | 1265580476
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Entity Type | Organization
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Legal Business Name | DAVID KOCH
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Dates
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Enumeration Date | 01/07/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 3621 59TH ST
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City | KENOSHA
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State | WI
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Zip | 53144-6921
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Country | US
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Telephone | 262-620-1650
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Fax | 262-653-0835
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Provider Business Mailing Address
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Address Line | 3621 59TH ST
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City | KENOSHA
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State | WI
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Zip | 53144-6921
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Country | US
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Telephone | 262-620-1650
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Fax | 262-653-0835
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Authorized Official
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Title or Position | OWNER
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Name | MR. DAVID E KOCH
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Credential | A.T.C
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Telephone | 262-620-1650
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 270-039
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License Number State | WI
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