Provider Demographics
NPI:1386621050
Name:KOCH, KENNETH ROBERT (DC)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:ROBERT
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 1:3449 E PLANKINTON AVE
Mailing Address - Street 2:
Mailing Address - City:CUDAHY
Mailing Address - State:WI
Mailing Address - Zip Code:53110-1413
Mailing Address - Country:US
Mailing Address - Phone:414-483-1060
Mailing Address - Fax:414-483-1847
Practice Address - Street 1:3449 E PLANKINTON AVE
Practice Address - Street 2:
Practice Address - City:CUDAHY
Practice Address - State:WI
Practice Address - Zip Code:53110-1413
Practice Address - Country:US
Practice Address - Phone:414-483-1060
Practice Address - Fax:414-483-1847
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-23
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI1992012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
75265Medicare ID - Type Unspecified
T62454Medicare UPIN