Healthcare Provider Details

I. General information

NPI: 1134030711
Provider Name (Legal Business Name): RYAN KOTECKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 E LINCOLN HWY
NEW LENOX IL
60451-9534
US

IV. Provider business mailing address

18213 IMPERIAL LN
ORLAND PARK IL
60467-5297
US

V. Phone/Fax

Practice location:
  • Phone: 815-215-8200
  • Fax:
Mailing address:
  • Phone: 616-914-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: