1508070475 NPI number — DEANNE ELIZABETH KIBA DO, FAARFM

Table of content: DEANNE ELIZABETH KIBA DO, FAARFM (NPI 1508070475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508070475 NPI number — DEANNE ELIZABETH KIBA DO, FAARFM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIBA
Provider First Name:
DEANNE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO, FAARFM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508070475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6436 ADAMS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON TOWNSHIP
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48094-1238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
330-988-2207
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
543 N MAIN ST STE 122
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48307-1485
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-601-5055
Provider Business Practice Location Address Fax Number:
248-659-1639
Provider Enumeration Date:
05/10/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  8892 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: 3307946 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)