Healthcare Provider Details

I. General information

NPI: 1700379914
Provider Name (Legal Business Name): CHARLES WILLIAM KUDER JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 06/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3990 JOHN R ST
DETROIT MI
48201-2018
US

IV. Provider business mailing address

3607 HANNAN RD APT 114
WAYNE MI
48184-2830
US

V. Phone/Fax

Practice location:
  • Phone: 313-745-8058
  • Fax:
Mailing address:
  • Phone: 734-255-8894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5201009701
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: