Healthcare Provider Details

I. General information

NPI: 1235617259
Provider Name (Legal Business Name): TRENT KUCERA DPT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SPRINGFIELD DR
BLOOMINGDALE IL
60108
US

IV. Provider business mailing address

1860 PAYSPHERE CIR
CHICAGO IL
60674-0018
US

V. Phone/Fax

Practice location:
  • Phone: 630-469-9200
  • Fax:
Mailing address:
  • Phone: 630-967-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: