Healthcare Provider Details

I. General information

NPI: 1255990552
Provider Name (Legal Business Name): KBOOSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 06/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3008 JUNEBERRY AVE SE
GRAND RAPIDS MI
49508-1523
US

IV. Provider business mailing address

3008 JUNEBERRY AVE SE
GRAND RAPIDS MI
49508-1523
US

V. Phone/Fax

Practice location:
  • Phone: 616-228-3324
  • Fax:
Mailing address:
  • Phone: 616-228-3324
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: ANNIE M YOUNG
Title or Position: CEO
Credential:
Phone: 616-228-3324