Provider Demographics
NPI:1336200153
Name:KOCH, DARREN T (DC)
Entity Type:Individual
Prefix:DR
First Name:DARREN
Middle Name:T
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:P.O. BOX 623
Mailing Address - Street 2:
Mailing Address - City:LEESPORT
Mailing Address - State:PA
Mailing Address - Zip Code:19533
Mailing Address - Country:US
Mailing Address - Phone:610-926-8030
Mailing Address - Fax:610-926-2828
Practice Address - Street 1:SCHOOLSIDE PLAZA
Practice Address - Street 2:SUITE 102
Practice Address - City:LEESPORT
Practice Address - State:PA
Practice Address - Zip Code:19533
Practice Address - Country:US
Practice Address - Phone:610-926-8030
Practice Address - Fax:610-926-2828
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC-006944-L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA702162Medicare ID - Type Unspecified