Healthcare Provider Details

I. General information

NPI: 1275797359
Provider Name (Legal Business Name): NICHOLAS KUKICH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 NORTHLINE RD
SOUTHGATE MI
48195-2277
US

IV. Provider business mailing address

2090 THOMAS ST
LINCOLN PARK MI
48146-4801
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: