Healthcare Provider Details

I. General information

NPI: 1902204290
Provider Name (Legal Business Name): BRANDON KOWACICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 MESQUITE TRL
BENBROOK TX
76126-3811
US

IV. Provider business mailing address

1305 MESQUITE TRL
BENBROOK TX
76126-3811
US

V. Phone/Fax

Practice location:
  • Phone: 417-522-4098
  • Fax:
Mailing address:
  • Phone: 417-522-4098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2092157
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: