Provider Demographics
NPI:1659484574
Name:KOCH CHIROPRACTIC AND WELLNESS CENTER
Entity Type:Organization
Organization Name:KOCH CHIROPRACTIC AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:715-256-9616
Mailing Address - Street 1:1990 GODFREY DR
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981-7908
Mailing Address - Country:US
Mailing Address - Phone:715-256-9616
Mailing Address - Fax:715-256-9618
Practice Address - Street 1:1990 GODFREY DR
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-7908
Practice Address - Country:US
Practice Address - Phone:715-256-9616
Practice Address - Fax:715-256-9618
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3449-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38902900Medicaid
WI38902900Medicaid