Provider Demographics
NPI:1649362732
Name:KLUCK, RYAN P (DPT)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:P
Last Name:KLUCK
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-3251
Practice Address - Street 1:1290 N SUMMIT AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4459
Practice Address - Country:US
Practice Address - Phone:262-468-3480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070014460225100000X
WI12270-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK19413Medicare PIN
WIK400108899Medicare PIN
ILK53469Medicare PIN
WIK400108903Medicare PIN
ILR00864Medicare PIN
ILP00361388Medicare PIN