MEDICARE: MS. AMY KULCZYCKI ATC, CSCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1265450803
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AMY KULCZYCKI ATC, CSCS

Provider Business Mailing Address
First Line	:	1176 POMONA DR
Second Line	:
City	:	CHAMPAIGN
State	:	IL
Zip	:	61822-1857
Country	:	US
Telephone Number	:	217-390-4877
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 S SHELDON ST
Second Line	:
City	:	RANTOUL
State	:	IL
Zip	:	61866-2431
Country	:	US
Telephone Number	:	217-892-2151
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2006
Last Update Date	:	07/08/2007

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