Provider Demographics
NPI:1366489304
Name:KOEPPEN, KURT (PT)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:
Last Name:KOEPPEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:3441 ALMA ST
Practice Address - Street 2:SUITE 200
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-3506
Practice Address - Country:US
Practice Address - Phone:650-323-4440
Practice Address - Fax:650-323-4441
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16073225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16073OtherPT LICENCE #
CA0PT160270Medicare PIN