Healthcare Provider Details

I. General information

NPI: 1467776617
Provider Name (Legal Business Name): KIRK DOUGLAS ROUNDS RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2010
Last Update Date: 03/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W MAIN ST
MARION IL
62959-1188
US

IV. Provider business mailing address

2401 WEST MAIN MARION VA
MARION IL
62595
US

V. Phone/Fax

Practice location:
  • Phone: 161-899-7531
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number104330
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: