Provider Demographics
NPI:1225802093
Name:KULPA, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:KULPA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3545 N VERMILION ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-1100
Mailing Address - Country:US
Mailing Address - Phone:217-651-6801
Mailing Address - Fax:217-651-6802
Practice Address - Street 1:3545 N VERMILION ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-1100
Practice Address - Country:US
Practice Address - Phone:217-651-6801
Practice Address - Fax:217-651-6802
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INMT20901677225700000X
IL227007700225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist