Healthcare Provider Details

I. General information

NPI: 1669010864
Provider Name (Legal Business Name): CHELCI KUIACK DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15501 METRO PKWY STE 102
CLINTON TOWNSHIP MI
48036-1684
US

IV. Provider business mailing address

11630 WEINGARTZ W
UTICA MI
48315-5933
US

V. Phone/Fax

Practice location:
  • Phone: 596-697-7000
  • Fax:
Mailing address:
  • Phone: 316-650-5739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019374
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: