Healthcare Provider Details

I. General information

NPI: 1740290386
Provider Name (Legal Business Name): GLENN D. KUELTZO O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13231 W 143RD ST SUITE 101
HOMER GLEN IL
60491-6638
US

IV. Provider business mailing address

13231 W 143RD ST SUITE 101
HOMER GLEN IL
60491-6638
US

V. Phone/Fax

Practice location:
  • Phone: 708-301-2020
  • Fax: 708-301-0884
Mailing address:
  • Phone: 708-301-2020
  • Fax: 708-301-0884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: