Healthcare Provider Details

I. General information

NPI: 1922838713
Provider Name (Legal Business Name): CHESTER LEE KOWALSKI IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 YUKON AVE
YUKON OK
73099-4690
US

IV. Provider business mailing address

11709 TYSON CT
MIDWEST CITY OK
73130-8413
US

V. Phone/Fax

Practice location:
  • Phone: 405-265-4515
  • Fax:
Mailing address:
  • Phone: 325-280-3080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: