Healthcare Provider Details

I. General information

NPI: 1205292018
Provider Name (Legal Business Name): NICOLAI JOSEPH KOWALSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2016
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21301 WILLOW WISP ST
SAINT CLAIR SHORES MI
48082-1220
US

IV. Provider business mailing address

22229 LANSE ST
SAINT CLAIR SHORES MI
48081-2761
US

V. Phone/Fax

Practice location:
  • Phone: 586-879-5707
  • Fax:
Mailing address:
  • Phone: 586-879-5707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: