1144265513 NPI number — HEATHER A KIEBKE DPT

Table of content: HEATHER A KIEBKE DPT (NPI 1144265513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144265513 NPI number — HEATHER A KIEBKE DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIEBKE
Provider First Name:
HEATHER
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
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:
1144265513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/14/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2510 CHERRY HILL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT LAKES
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56501-8063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-640-8645
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1245 WASHINGTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT LAKES
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56501
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-846-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/18/2006

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: 225100000X , with the licence number:  6245 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 778237 . This is a "AMERICA'S PPO/ARAZ #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: DA9011040527 . This is a "PREFERRED ONE #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: ND400023 . This is a "LHS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 18166 . This is a "NDBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 74G75SO . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 17701 . This is a "NDBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 6404053 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 1144265513 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP38646 . This is a "HEALTHPARTNERS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 72D46SO . This is a "MNBS #" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 00F70SO . This is a "MNBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 17702 . This is a "NDBS #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 58998 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6401666 . This is a "MEDICA #" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".




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