Basic Information
| Provider Information | |||||||||
| NPI: | 1245690320 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUCK | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1802 GALLOWAY ST | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547033467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158318966 | ||||||||
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| Practice Location | |||||||||
| Address1: | 613 OAK ST | ||||||||
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| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2188283768 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 03/02/2016 | ||||||||
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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 | 237700000X | 2716 | MN | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.