MEDICARE: MRS. KRISTINA MARIE KOCH MPT

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	225100000X	Physical Therapist	PT25297	CA
2	2251G0304X	Geriatric Physical Therapist	PT25297	CA

General Provider Information

NPI Number	:	1770693509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KRISTINA MARIE KOCH MPT

Provider Business Mailing Address
First Line	:	13085 CRANE CANYON LOOP
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-7217
Country	:	US
Telephone Number	:	619-578-4362
Fax Number	:

Provider Business Practice Location Address
First Line	:	5265 N ACADEMY BLVD
Second Line	:	#1500
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80918-4060
Country	:	US
Telephone Number	:	719-694-8342
Fax Number	:	719-694-8347

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	01/28/2017

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