Healthcare Provider Details

I. General information

NPI: 1144314915
Provider Name (Legal Business Name): LISA MARIE KUKLIS R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 02/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BUNKER HILL DR
AITKIN MN
56431-1864
US

IV. Provider business mailing address

1593 EVERGREEN DR
CLOQUET MN
55720-8510
US

V. Phone/Fax

Practice location:
  • Phone: 218-927-5520
  • Fax: 218-429-3972
Mailing address:
  • Phone: 218-740-4060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2603
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: