Healthcare Provider Details

I. General information

NPI: 1598316549
Provider Name (Legal Business Name): MRS. LUCINDA LOIS KUTSKO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2019
Last Update Date: 09/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11105 N PALMYRA RD
NORTH JACKSON OH
44451-9725
US

IV. Provider business mailing address

11105 N PALMYRA RD
NORTH JACKSON OH
44451-9725
US

V. Phone/Fax

Practice location:
  • Phone: 330-727-4477
  • Fax:
Mailing address:
  • Phone: 330-727-4477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: