Provider Demographics
NPI:1649466053
Name:KOCH, KENNETH G (DC)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:G
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 1:9484 BLACK MOUNTAIN RD STE I
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4520
Mailing Address - Country:US
Mailing Address - Phone:858-484-8548
Mailing Address - Fax:
Practice Address - Street 1:9484 BLACK MOUNTAIN RD
Practice Address - Street 2:STE I
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4520
Practice Address - Country:US
Practice Address - Phone:858-484-8548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC14114111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC14114Medicare PIN