Healthcare Provider Details

I. General information

NPI: 1962944652
Provider Name (Legal Business Name): KOTZAN CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 WHITE OAK WAY
SAN CARLOS CA
94070-5109
US

IV. Provider business mailing address

1150 WHITE OAK WAY
SAN CARLOS CA
94070-5109
US

V. Phone/Fax

Practice location:
  • Phone: 650-593-3500
  • Fax:
Mailing address:
  • Phone: 650-593-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License NumberDC30809
License Number StateCA

VIII. Authorized Official

Name: PHILLIP DAVID KOTZAN
Title or Position: OWNER
Credential: DC
Phone: 408-373-6094