Healthcare Provider Details

I. General information

NPI: 1750633103
Provider Name (Legal Business Name): MALLORY KUHLMANN KUCHEM O.D., M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 07/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7400 STATE LINE RD
PRAIRIE VILLAGE KS
66208-3444
US

IV. Provider business mailing address

PO BOX 411851
KANSAS CITY MO
64141-1851
US

V. Phone/Fax

Practice location:
  • Phone: 913-588-6600
  • Fax:
Mailing address:
  • Phone: 913-588-6600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1936
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2012030550
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: