Provider Demographics
NPI:1326690728
Name:THEODORE M. KOUKLES DC PC
Entity Type:Organization
Organization Name:THEODORE M. KOUKLES DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOUKLES
Authorized Official - Suffix:
Authorized Official - Credentials:DC CCSP
Authorized Official - Phone:586-876-3737
Mailing Address - Street 1:44777 HAYES RD STE A
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1421
Mailing Address - Country:US
Mailing Address - Phone:586-876-3737
Mailing Address - Fax:
Practice Address - Street 1:44777 HAYES RD STE A
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1421
Practice Address - Country:US
Practice Address - Phone:586-876-3737
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty