MEDICARE: DR. JERRY I. KOCH DC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111NI0013X	Independent Medical Examiner Chiropractor	4468	TX

General Provider Information

NPI Number	:	1376749564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY I. KOCH DC

Provider Business Mailing Address
First Line	:	13400 BLANCO RD APT 202
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-2179
Country	:	US
Telephone Number	:	210-525-9900
Fax Number	:	210-525-9908

Provider Business Practice Location Address
First Line	:	12446 WEST AVE
Second Line	:	STE 100
City	:	SAN ANTONIO
State	:	TX
Zip	:	78216-2517
Country	:	US
Telephone Number	:	210-525-9900
Fax Number	:	210-525-9908

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/10/2007

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