Healthcare Provider Details

I. General information

NPI: 1659602662
Provider Name (Legal Business Name): ALAN KOTECKI PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10946 DEER VALLEY RD
YUCAIPA CA
92399-9490
US

IV. Provider business mailing address

10946 DEER VALLEY ROAD
YUCAIPA CA
92399
US

V. Phone/Fax

Practice location:
  • Phone: 909-260-3595
  • Fax:
Mailing address:
  • Phone: 909-260-3595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number25613
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: