Individual
KYLE MAKUCK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT
Contact information
Practice address
760 PILGRIM WAY, GREEN BAY, WI 54304-5263
(920) 496-4700
(920) 496-4705
Mailing address
PO BOX 19070, PREVEA HEALTH, GREEN BAY, WI 54307-9070
(920) 496-4700
(920) 496-4705
Taxonomy
Speciality
Code
Description
License number
State
225100000X
Physical Therapist
Primary
9686
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
40384300
—
WI
Enumeration date
07/27/2006
Last updated
07/08/2007
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