Healthcare Provider Details

I. General information

NPI: 1508688854
Provider Name (Legal Business Name): NICHOLAS KUKIELA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37450 SCHOOLCRAFT RD
LIVONIA MI
48150-1082
US

IV. Provider business mailing address

37450 SCHOOLCRAFT RD STE 110
LIVONIA MI
48150-1000
US

V. Phone/Fax

Practice location:
  • Phone: 734-458-4601
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number4704238692
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: