=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487630430
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY GEORGE KOTLARCZYK D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2005
-----------------------------------------------------
Last Update Date | 11/22/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9020 58TH DR EAST STE 102
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-756-5555
-----------------------------------------------------
Fax | 941-756-5556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | P.O. BOX 20247
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-756-5555
-----------------------------------------------------
Fax | 941-756-5556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH9102
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------