Healthcare Provider Details

I. General information

NPI: 1679657639
Provider Name (Legal Business Name): PHILLIP J KACZMAREK D.C., P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2448 UNION RD
CHEEKTOWAGA NY
14227-2230
US

IV. Provider business mailing address

2448 UNION RD
CHEEKTOWAGA NY
14227-2230
US

V. Phone/Fax

Practice location:
  • Phone: 716-656-0200
  • Fax: 716-656-0055
Mailing address:
  • Phone: 716-656-0200
  • Fax: 716-656-0055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License NumberX010491-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number018590-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: