Provider Demographics
NPI:1104330943
Name:KUGLITSCH ENTERPRISES, INC
Entity type:Organization
Organization Name:KUGLITSCH ENTERPRISES, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KUGLITSCH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:920-344-5237
Mailing Address - Street 1:3414 NW CACHE RD STE F
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-3878
Mailing Address - Country:US
Mailing Address - Phone:580-771-2008
Mailing Address - Fax:580-771-2030
Practice Address - Street 1:3414 NW CACHE RD STE F
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3878
Practice Address - Country:US
Practice Address - Phone:580-771-2008
Practice Address - Fax:817-771-2030
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPENDINGMedicaid