Healthcare Provider Details

I. General information

NPI: 1023849494
Provider Name (Legal Business Name): BLADE MORGAN KOWALSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 LAKE AVE # 2
WOODSTOCK IL
60098-7401
US

IV. Provider business mailing address

9619 MARCI LN
HEBRON IL
60034-9513
US

V. Phone/Fax

Practice location:
  • Phone: 815-337-7100
  • Fax:
Mailing address:
  • Phone: 815-528-2179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number160010187
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: