Healthcare Provider Details

I. General information

NPI: 1629696216
Provider Name (Legal Business Name): NATHAN RYAN KUCK DPT, PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9368 N LILLEY RD
PLYMOUTH MI
48170-4610
US

IV. Provider business mailing address

9368 N LILLEY RD
PLYMOUTH MI
48170-4610
US

V. Phone/Fax

Practice location:
  • Phone: 734-416-3900
  • Fax:
Mailing address:
  • Phone: 734-416-3900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501019630
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: