Provider Demographics
NPI:1821348707
Name:ROTACH, KELLEN (PT)
Entity Type:Individual
Prefix:
First Name:KELLEN
Middle Name:
Last Name:ROTACH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:383 WHITE SPRUCE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14623-1603
Mailing Address - Country:US
Mailing Address - Phone:585-442-6067
Mailing Address - Fax:585-442-6073
Practice Address - Street 1:349 W COMMERCIAL ST
Practice Address - Street 2:STE 1275
Practice Address - City:EAST ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14445-2407
Practice Address - Country:US
Practice Address - Phone:585-264-0370
Practice Address - Fax:585-264-0432
Is Sole Proprietor?:No
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY035528-1225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist