Healthcare Provider Details

I. General information

NPI: 1811031966
Provider Name (Legal Business Name): KEVIN LEO KUKLA O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 N LEWIS AVE
WAUKEGAN IL
60087-2231
US

IV. Provider business mailing address

7430 ASTOR AVE
HANOVER PARK IL
60133-3139
US

V. Phone/Fax

Practice location:
  • Phone: 847-599-1185
  • Fax:
Mailing address:
  • Phone: 630-362-8592
  • Fax:

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: