Healthcare Provider Details

I. General information

NPI: 1801120639
Provider Name (Legal Business Name): KEVIN KUCKO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2009
Last Update Date: 09/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 MEDICAL PARK RD STE 105
MOORESVILLE NC
28117-8527
US

IV. Provider business mailing address

20221 HAMMOCK OAK DR
CORNELIUS NC
28031-6813
US

V. Phone/Fax

Practice location:
  • Phone: 704-806-9826
  • Fax:
Mailing address:
  • Phone: 704-806-9826
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number6830
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: