MEDICARE: JACOB KOTLICKY ATC/LAT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	AL2874	FL

General Provider Information

NPI Number	:	1720494644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB KOTLICKY ATC/LAT

Provider Business Mailing Address
First Line	:	3403 ISLAND RD
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33026-1249
Country	:	US
Telephone Number	:	954-594-1883
Fax Number	:

Provider Business Practice Location Address
First Line	:	3403 ISLAND RD
Second Line	:
City	:	HOLLYWOOD
State	:	FL
Zip	:	33026-1249
Country	:	US
Telephone Number	:	954-594-1883
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/11/2014
Last Update Date	:	07/11/2014

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