Provider Demographics
NPI:1770797003
Name:KOCH CHIROPRACTIC P.C.
Entity type:Organization
Organization Name:KOCH CHIROPRACTIC P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:C
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:724-934-0001
Mailing Address - Street 1:11959 PERRY HWY
Mailing Address - Street 2:
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-8602
Mailing Address - Country:US
Mailing Address - Phone:724-934-0001
Mailing Address - Fax:724-934-5599
Practice Address - Street 1:11959 PERRY HWY
Practice Address - Street 2:
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-8602
Practice Address - Country:US
Practice Address - Phone:724-934-0001
Practice Address - Fax:724-934-5599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC004706L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1592870OtherBLUE SHIELD
PA075367Medicare ID - Type Unspecified