Healthcare Provider Details

I. General information

NPI: 1437551975
Provider Name (Legal Business Name): KIRK DAHLSTROM RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 JOHN R ST
DETROIT MI
48201-1916
US

IV. Provider business mailing address

4646 JOHN R ST
DETROIT MI
48201-1916
US

V. Phone/Fax

Practice location:
  • Phone: 313-576-1000
  • Fax: 313-576-3723
Mailing address:
  • Phone: 313-576-1000
  • Fax: 313-576-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number4401004101
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: