Healthcare Provider Details

I. General information

NPI: 1427591171
Provider Name (Legal Business Name): STEPHEN GEORGE KOWALSKI JR. ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2016
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 MADISON AVE
RAHWAY NJ
07065-1803
US

IV. Provider business mailing address

612 S CHESTNUT ST
WESTFIELD NJ
07090-1351
US

V. Phone/Fax

Practice location:
  • Phone: 732-396-1090
  • Fax:
Mailing address:
  • Phone: 908-447-4756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number25MT00179800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: