Provider Demographics
NPI:1861454795
Name:KOCH, CHAD (ATC)
Entity Type:Individual
Prefix:MR
First Name:CHAD
Middle Name:
Last Name:KOCH
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 S PRAIRIE AVE
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-2139
Mailing Address - Country:US
Mailing Address - Phone:815-802-0512
Mailing Address - Fax:
Practice Address - Street 1:350 MAIN ST NW
Practice Address - Street 2:
Practice Address - City:BOURBONNAIS
Practice Address - State:IL
Practice Address - Zip Code:60914-2383
Practice Address - Country:US
Practice Address - Phone:815-936-1855
Practice Address - Fax:815-936-6097
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer