Healthcare Provider Details

I. General information

NPI: 1871860874
Provider Name (Legal Business Name): CINDY KUDELKA LAC, MSTOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2011
Last Update Date: 03/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1011 W WELLINGTON AVE STE 220
CHICAGO IL
60657-7187
US

IV. Provider business mailing address

4308 W 55TH ST
CHICAGO IL
60632-4628
US

V. Phone/Fax

Practice location:
  • Phone: 847-579-9882
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198.000991
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: