Healthcare Provider Details

I. General information

NPI: 1891578720
Provider Name (Legal Business Name): BRIAN KOBAK PT, DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

823 PARK EAST BLVD STE B
LAFAYETTE IN
47905-0811
US

IV. Provider business mailing address

823 PARK EAST BLVD STE B
LAFAYETTE IN
47905-0811
US

V. Phone/Fax

Practice location:
  • Phone: 765-297-0975
  • Fax:
Mailing address:
  • Phone: 765-297-0975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number05015190A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: