Healthcare Provider Details

I. General information

NPI: 1740579192
Provider Name (Legal Business Name): PUNITA SOOD KUKREJA D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 QUAIL ST
ZION IL
60099-5420
US

IV. Provider business mailing address

4200 QUAIL ST
ZION IL
60099-5420
US

V. Phone/Fax

Practice location:
  • Phone: 262-498-6479
  • Fax:
Mailing address:
  • Phone: 262-498-6479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038011643
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: