Healthcare Provider Details

I. General information

NPI: 1891802583
Provider Name (Legal Business Name): KOWASIC ENTERPRISES INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 N DYSART RD SUITE 103
AVONDALE AZ
85323-1538
US

IV. Provider business mailing address

1461 N DYSART RD SUITE 103
AVONDALE AZ
85323-1538
US

V. Phone/Fax

Practice location:
  • Phone: 623-932-5505
  • Fax: 623-925-0752
Mailing address:
  • Phone: 623-932-5505
  • Fax: 623-925-0752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: MRS. TRACY LYNN KOWASIC
Title or Position: VICE PRESIDENT/SECRETARY/SALES
Credential:
Phone: 623-932-5505