Provider Demographics
NPI:1649343856
Name:KUKA, KELLY V (DC)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:V
Last Name:KUKA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9035 BLAISDELL AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-3617
Mailing Address - Country:US
Mailing Address - Phone:612-644-7193
Mailing Address - Fax:
Practice Address - Street 1:12805 STATE HIGHWAY 55
Practice Address - Street 2:SUITE 208
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441
Practice Address - Country:US
Practice Address - Phone:763-557-7399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN350003617Medicare ID - Type Unspecified