Healthcare Provider Details

I. General information

NPI: 1730480765
Provider Name (Legal Business Name): KOTILA MASSAGE & WELLNESS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 PAULS DR SUITE 102
BRANDON FL
33511-4801
US

IV. Provider business mailing address

330 PAULS DR SUITE 102
BRANDON FL
33511-4801
US

V. Phone/Fax

Practice location:
  • Phone: 813-643-1242
  • Fax:
Mailing address:
  • Phone: 813-643-1242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA 47791
License Number StateFL

VIII. Authorized Official

Name: GARY J KOTILA
Title or Position: PRESIDENT
Credential: D.C.
Phone: 813-643-1242