Healthcare Provider Details

I. General information

NPI: 1629839667
Provider Name (Legal Business Name): PAUL KUCHARYSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/17/2024
Certification Date: 01/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2923 LAKE VERNA DR
LOVELAND CO
80538-7193
US

IV. Provider business mailing address

2923 LAKE VERNA DR
LOVELAND CO
80538-7193
US

V. Phone/Fax

Practice location:
  • Phone: 720-237-5756
  • Fax:
Mailing address:
  • Phone: 720-237-5756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number0004932
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: