Provider Demographics
NPI:1376615914
Name:KOWALCZUK, RICHARD A (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:A
Last Name:KOWALCZUK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 BRICE ROAD
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068
Mailing Address - Country:US
Mailing Address - Phone:614-864-2000
Mailing Address - Fax:614-864-9121
Practice Address - Street 1:1528 BRICE ROAD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068
Practice Address - Country:US
Practice Address - Phone:614-864-2000
Practice Address - Fax:614-864-9121
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH859111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0456279Medicaid
KO0491963Medicare ID - Type Unspecified
OH0456279Medicaid