MEDICARE: JOHN B KOLODZIEJCZAK P.T.A.

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	225200000X	Physical Therapy Assistant	2034122	TX

General Provider Information

NPI Number	:	1679889091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN B KOLODZIEJCZAK P.T.A.

Provider Business Mailing Address
First Line	:	7502B AMHERST DR
Second Line	:
City	:	ROWLETT
State	:	TX
Zip	:	75088-6372
Country	:	US
Telephone Number	:	214-284-9544
Fax Number	:	972-599-1867

Provider Business Practice Location Address
First Line	:	12222 N CENTRAL EXPY
Second Line	:	STE 115
City	:	DALLAS
State	:	TX
Zip	:	75243-3720
Country	:	US
Telephone Number	:	972-546-0411
Fax Number	:	972-599-1867

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

Provider Enumeration Date	:	08/23/2010
Last Update Date	:	08/23/2010

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