Healthcare Provider Details

I. General information

NPI: 1740682269
Provider Name (Legal Business Name): MARK TKACZUK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5478 WILSHIRE BLVD STE 208
LOS ANGELES CA
90036-4225
US

IV. Provider business mailing address

5478 WILSHIRE BLVD STE 208
LOS ANGELES CA
90036-4225
US

V. Phone/Fax

Practice location:
  • Phone: 323-936-7525
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number41686
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: