Healthcare Provider Details

I. General information

NPI: 1487630430
Provider Name (Legal Business Name): GREGORY GEORGE KOTLARCZYK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 11/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9020 58TH DR EAST STE 102
BRADENTON FL
34202
US

IV. Provider business mailing address

P.O. BOX 20247
BRADENTON FL
34204
US

V. Phone/Fax

Practice location:
  • Phone: 941-756-5555
  • Fax: 941-756-5556
Mailing address:
  • Phone: 941-756-5555
  • Fax: 941-756-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9102
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: