Healthcare Provider Details

I. General information

NPI: 1164439105
Provider Name (Legal Business Name): CHAD LORAN KUDLACEK OTR L, CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 S BURLINGTON AVE
HASTINGS NE
68901-5905
US

IV. Provider business mailing address

207 S BURLINGTON AVE
HASTINGS NE
68901-5905
US

V. Phone/Fax

Practice location:
  • Phone: 402-462-8824
  • Fax: 402-462-8017
Mailing address:
  • Phone: 402-462-8824
  • Fax: 402-462-8017

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number946
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: