Healthcare Provider Details

I. General information

NPI: 1568022184
Provider Name (Legal Business Name): HALLIE KUCHERA OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2019
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2027 CROSSROADS BLVD
WATERLOO IA
50702-4405
US

IV. Provider business mailing address

816 LISA DR
WATERLOO IA
50701-5212
US

V. Phone/Fax

Practice location:
  • Phone: 319-505-2142
  • Fax:
Mailing address:
  • Phone: 319-296-5960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number096272
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: