Healthcare Provider Details

I. General information

NPI: 1811348576
Provider Name (Legal Business Name): KATHRYN KUTAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 POLLARD DR
LAKE ODESSA MI
48849-9317
US

IV. Provider business mailing address

464 POLLARD DR
LAKE ODESSA MI
48849-9317
US

V. Phone/Fax

Practice location:
  • Phone: 517-881-1950
  • Fax:
Mailing address:
  • Phone: 517-881-1950
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberK 320 461 594 022
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: