Healthcare Provider Details

I. General information

NPI: 1518139997
Provider Name (Legal Business Name): LARHONDA NICOLE TRIBBLE OWNER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2008
Last Update Date: 03/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15810 LAKESIDE VILLAGE DR APT. 205
CLINTON TOWNSHIP MI
48038-6118
US

IV. Provider business mailing address

15810 LAKESIDE VILLAGE DR APT. 205
CLINTON TOWNSHIP MI
48038-6118
US

V. Phone/Fax

Practice location:
  • Phone: 586-876-2298
  • Fax: 586-421-4637
Mailing address:
  • Phone: 586-876-2298
  • Fax: 586-421-4637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberT614488630898
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: