Healthcare Provider Details

I. General information

NPI: 1538134697
Provider Name (Legal Business Name): DAVID KUCK PT DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 MAIN RD STE 4
RIVERHEAD NY
11901-1953
US

IV. Provider business mailing address

31 MAIN RD STE 4
RIVERHEAD NY
11901-1953
US

V. Phone/Fax

Practice location:
  • Phone: 631-208-2900
  • Fax: 631-208-2929
Mailing address:
  • Phone: 631-208-2900
  • Fax: 631-208-2929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number025601 0
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: