Healthcare Provider Details

I. General information

NPI: 1073427217
Provider Name (Legal Business Name): KIRBY MIGUEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2759 S JALEN CT
BLOOMINGTON IN
47403-3244
US

IV. Provider business mailing address

2759 S JALEN CT
BLOOMINGTON IN
47403-3244
US

V. Phone/Fax

Practice location:
  • Phone: 812-340-9412
  • Fax:
Mailing address:
  • Phone: 812-340-9412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number06004422A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: