Healthcare Provider Details

I. General information

NPI: 1003639717
Provider Name (Legal Business Name): MICHAEL RUSSELL KUCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2024
Last Update Date: 11/02/2024
Certification Date: 11/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 HURON BLVD
MARYSVILLE MI
48040-1421
US

IV. Provider business mailing address

5039 VILLA LINDE PKWY STE 30
FLINT MI
48532-3450
US

V. Phone/Fax

Practice location:
  • Phone: 989-401-2244
  • Fax:
Mailing address:
  • Phone: 989-401-2244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: