Healthcare Provider Details

I. General information

NPI: 1649255852
Provider Name (Legal Business Name): JUSTIN MARK KOTLARCZYK PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2005
Last Update Date: 08/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2722 MANATEE AVE W SUITE 2
BRADENTON FL
34205-4945
US

IV. Provider business mailing address

100 3RD AVE W STE 110
BRADENTON FL
34205-8641
US

V. Phone/Fax

Practice location:
  • Phone: 941-744-9046
  • Fax: 941-744-9046
Mailing address:
  • Phone: 941-708-9555
  • Fax: 941-708-5200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT21555
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: