Healthcare Provider Details

I. General information

NPI: 1154731909
Provider Name (Legal Business Name): MATHEW JOHN KULAS L.AC.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 KERCHEVAL AVE
GROSSE POINTE FARMS MI
48236-3610
US

IV. Provider business mailing address

159 KERCHEVAL AVE
GROSSE POINTE FARMS MI
48236-3610
US

V. Phone/Fax

Practice location:
  • Phone: 312-533-9493
  • Fax: 313-640-2548
Mailing address:
  • Phone: 312-533-9493
  • Fax: 313-640-2548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number198001202
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: