Basic Information
| Provider Information | |||||||||
| NPI: | 1952761595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOTAK | ||||||||
| FirstName: | JIMMY | ||||||||
| MiddleName: | BHADRESH KUMAR | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 29125 BUCKINGHAM ST | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481544480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485654000 | ||||||||
| FaxNumber: | 2485654030 | ||||||||
| Practice Location | |||||||||
| Address1: | 29125 BUCKINGHAM ST | ||||||||
| Address2: | SUITE 2A | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481544480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485654000 | ||||||||
| FaxNumber: | 2485654030 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2016 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 5502004838 | MI | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.