Healthcare Provider Details

I. General information

NPI: 1629846084
Provider Name (Legal Business Name): KAELAN KOWALICK DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2023
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12023 N RADIO STATION RD STE A
SENECA SC
29678-1143
US

IV. Provider business mailing address

790 REMINGTON BLVD
BOLINGBROOK IL
60440-4909
US

V. Phone/Fax

Practice location:
  • Phone: 864-985-0770
  • Fax:
Mailing address:
  • Phone: 866-370-8206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number051781
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: