Healthcare Provider Details

I. General information

NPI: 1710339791
Provider Name (Legal Business Name): PETER KOWALCZYK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5110 N DYSART RD STE 148
LITCHFIELD PARK AZ
85340-3062
US

IV. Provider business mailing address

15410 S MOUNTAIN PKWY STE 112
PHOENIX AZ
85044-6691
US

V. Phone/Fax

Practice location:
  • Phone: 623-547-4739
  • Fax: 623-536-2154
Mailing address:
  • Phone: 480-706-1161
  • Fax: 480-706-7997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070.022416
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12902
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: