Healthcare Provider Details

I. General information

NPI: 1598382905
Provider Name (Legal Business Name): KEVIN POOLE JR. REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2020
Last Update Date: 07/01/2020
Certification Date: 07/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3044 SHABAY DR BLDG 1
FLUSHING MI
48433-2459
US

IV. Provider business mailing address

3044 SHABAY DR BLDG 1
FLUSHING MI
48433-2459
US

V. Phone/Fax

Practice location:
  • Phone: 810-265-8514
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number4704350959
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: