MEDICARE: DAVID S KISICKI PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	5621	AZ

General Provider Information

NPI Number	:	1184670598
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID S KISICKI PT

Provider Business Mailing Address
First Line	:	6520 W HAPPY VALLEY RD
Second Line	:	STE B 109
City	:	GLENDALE
State	:	AZ
Zip	:	85310-2615
Country	:	US
Telephone Number	:	623-561-1300
Fax Number	:	623-561-0036

Provider Business Practice Location Address
First Line	:	6520 W HAPPY VALLEY RD
Second Line	:	STE B 109
City	:	GLENDALE
State	:	AZ
Zip	:	85310-2615
Country	:	US
Telephone Number	:	623-561-1300
Fax Number	:	623-561-0036

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	06/23/2010

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