Healthcare Provider Details

I. General information

NPI: 1437974730
Provider Name (Legal Business Name): STEPHEN KUCLO IHP L2, HPH, EMT-P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2024
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16633 DALLAS PKWY STE 150
ADDISON TX
75001-6812
US

IV. Provider business mailing address

4109 REPUBLICAN BRANCH DR
PROSPER TX
75078-9825
US

V. Phone/Fax

Practice location:
  • Phone: 469-999-6985
  • Fax:
Mailing address:
  • Phone: 469-999-6985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number276794406
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: