Healthcare Provider Details

I. General information

NPI: 1174917942
Provider Name (Legal Business Name): DAVID KUCERA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2015
Last Update Date: 03/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2112 LYNDALE AVE S
MINNEAPOLIS MN
55405-3026
US

IV. Provider business mailing address

8979 VINEWOOD LN N
MAPLE GROVE MN
55369-9124
US

V. Phone/Fax

Practice location:
  • Phone: 612-874-1313
  • Fax: 612-874-6767
Mailing address:
  • Phone: 763-498-1986
  • Fax: 612-874-6767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: