Healthcare Provider Details

I. General information

NPI: 1316662273
Provider Name (Legal Business Name): MR. RAYMOND EDWARD KOZIRESKI JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 10/04/2022
Certification Date: 10/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 GLENMERE COVE RD
GOSHEN NY
10924-6059
US

IV. Provider business mailing address

2 GLENMERE COVE RD
GOSHEN NY
10924-6059
US

V. Phone/Fax

Practice location:
  • Phone: 845-291-4740
  • Fax:
Mailing address:
  • Phone: 845-291-4740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP117441
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: