Provider Demographics
NPI:1215985817
Name:KOCH, KEVIN PAUL (DC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:PAUL
Last Name:KOCH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:223 MULBERRY ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:PA
Mailing Address - Zip Code:17074-1421
Mailing Address - Country:US
Mailing Address - Phone:717-567-3158
Mailing Address - Fax:
Practice Address - Street 1:223 MULBERRY ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:PA
Practice Address - Zip Code:17074-1421
Practice Address - Country:US
Practice Address - Phone:717-567-3158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002254L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
K0150052Medicare ID - Type Unspecified