Healthcare Provider Details

I. General information

NPI: 1992205348
Provider Name (Legal Business Name): KEITH KOWALCZYK DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2018
Last Update Date: 02/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 N LAKE AVE
PASADENA CA
91104-2301
US

IV. Provider business mailing address

1450 N LAKE AVE
PASADENA CA
91104-2301
US

V. Phone/Fax

Practice location:
  • Phone: 626-798-7805
  • Fax: 626-798-7800
Mailing address:
  • Phone: 626-798-7805
  • Fax: 626-798-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number34122
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: