Healthcare Provider Details

I. General information

NPI: 1073944609
Provider Name (Legal Business Name): JOEL MORRIS KUPERMAN L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOEL M KUPERMAN DA

II. Dates (important events)

Enumeration Date: 12/08/2013
Last Update Date: 12/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1324 S GRAND AVE W
SPRINGFIELD IL
62704-3465
US

IV. Provider business mailing address

1324 S GRAND AVE W
SPRINGFIELD IL
62704-3465
US

V. Phone/Fax

Practice location:
  • Phone: 847-777-9200
  • Fax:
Mailing address:
  • Phone: 847-777-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number198001162
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198001162
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: