Provider Demographics
NPI:1134883861
Name:MARK KOCH DC LLC
Entity type:Organization
Organization Name:MARK KOCH DC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-784-8232
Mailing Address - Street 1:1055 LEGION DR
Mailing Address - Street 2:
Mailing Address - City:ELM GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53122-2202
Mailing Address - Country:US
Mailing Address - Phone:262-784-8232
Mailing Address - Fax:262-784-4139
Practice Address - Street 1:1055 LEGION DR
Practice Address - Street 2:
Practice Address - City:ELM GROVE
Practice Address - State:WI
Practice Address - Zip Code:53122-2202
Practice Address - Country:US
Practice Address - Phone:262-784-8232
Practice Address - Fax:262-784-4139
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty