Provider Demographics
NPI:1245362920
Name:KRUCKEBERG, RICHARD WARREN (PT, OCS, CHT)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:WARREN
Last Name:KRUCKEBERG
Suffix:
Gender:M
Credentials:PT, OCS, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PROFESSIONAL PLZ
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-9252
Mailing Address - Country:US
Mailing Address - Phone:217-345-1245
Mailing Address - Fax:217-345-1253
Practice Address - Street 1:100 PROFESSIONAL PLZ
Practice Address - Street 2:
Practice Address - City:MATTOON
Practice Address - State:IL
Practice Address - Zip Code:61938-9252
Practice Address - Country:US
Practice Address - Phone:217-345-1245
Practice Address - Fax:217-345-1253
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070.002766225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL204580Medicare ID - Type Unspecified