1386641884 NPI number — KIRBY KENNETH PERRAULT DC

Table of content: KIRBY KENNETH PERRAULT DC (NPI 1386641884)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386641884 NPI number — KIRBY KENNETH PERRAULT DC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PERRAULT
Provider First Name:
KIRBY
Provider Middle Name:
KENNETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DC
Provider Gender Code:
M

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:
1386641884
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/17/2006
NPI Reactivation Date:
03/27/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2199 JOLLY RD
Provider Second Line Business Mailing Address:
SUITE # 140
Provider Business Mailing Address City Name:
OKEMOS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48864-3968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-381-1880
Provider Business Mailing Address Fax Number:
517-381-1990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2199 JOLLY RD
Provider Second Line Business Practice Location Address:
SUITE # 140
Provider Business Practice Location Address City Name:
OKEMOS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48864-3968
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-381-1880
Provider Business Practice Location Address Fax Number:
517-381-1990
Provider Enumeration Date:
06/30/2005

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: 111N00000X , with the licence number:  2301007563 , 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)

  • Identifier: 950C350 750 . This is a "BCBS PIN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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