MEDICARE: MR. RICHARD WARREN KRUCKEBERG P.T., O.C.S., C.H.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	070.002766	IL

General Provider Information

NPI Number	:	1245362920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICHARD WARREN KRUCKEBERG P.T., O.C.S., C.H.T.

Provider Business Mailing Address
First Line	:	100 PROFESSIONAL PLZ
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9252
Country	:	US
Telephone Number	:	217-345-1245
Fax Number	:	217-345-1253

Provider Business Practice Location Address
First Line	:	100 PROFESSIONAL PLZ
Second Line	:
City	:	MATTOON
State	:	IL
Zip	:	61938-9252
Country	:	US
Telephone Number	:	217-345-1245
Fax Number	:	217-345-1253

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	09/19/2011

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