Healthcare Provider Details

I. General information

NPI: 1316475437
Provider Name (Legal Business Name): DAVID KOWALCZIK PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 06/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 WHITTER WAY
GHENT NY
12075-3213
US

IV. Provider business mailing address

27 ELM ST
WHITESBORO NY
13492-1203
US

V. Phone/Fax

Practice location:
  • Phone: 518-828-0800
  • Fax:
Mailing address:
  • Phone: 315-723-1051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number002302-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: