=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487784161
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS CONCEPTS OF FLORIDA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 10/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9020 58TH DRIVE 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 | PO BOX 20247
-----------------------------------------------------
City | BRADENTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 941-756-5555
-----------------------------------------------------
Fax | 941-756-5556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. GREGORY GEORGE KOTLARCZYK
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 941-756-5555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 9102
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CH9102
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------