Provider Demographics
NPI:1962944652
Name:KOTZAN CHIROPRACTIC
Entity type:Organization
Organization Name:KOTZAN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KOTZAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:408-373-6094
Mailing Address - Street 1:1150 WHITE OAK WAY
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-5109
Mailing Address - Country:US
Mailing Address - Phone:650-593-3500
Mailing Address - Fax:
Practice Address - Street 1:1150 WHITE OAK WAY
Practice Address - Street 2:
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-5109
Practice Address - Country:US
Practice Address - Phone:650-593-3500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC30809111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BG054Medicare PIN