Healthcare Provider Details

I. General information

NPI: 1952761595
Provider Name (Legal Business Name): JIMMY BHADRESH KUMAR KOTAK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2016
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29125 BUCKINGHAM ST SUITE 2A
LIVONIA MI
48154-4480
US

IV. Provider business mailing address

29125 BUCKINGHAM ST SUITE 2A
LIVONIA MI
48154-4480
US

V. Phone/Fax

Practice location:
  • Phone: 248-565-4000
  • Fax: 248-565-4030
Mailing address:
  • Phone: 248-565-4000
  • Fax: 248-565-4030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number5502004838
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: