Healthcare Provider Details

I. General information

NPI: 1861430035
Provider Name (Legal Business Name): THOMAS KOWALICK MSPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 12/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 LANAKILA PL
KIHEI HI
96753-8931
US

IV. Provider business mailing address

122 LANAKILA PL
KIHEI HI
96753-8931
US

V. Phone/Fax

Practice location:
  • Phone: 808-463-7055
  • Fax:
Mailing address:
  • Phone: 808-463-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2580
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: