Healthcare Provider Details

I. General information

NPI: 1053597914
Provider Name (Legal Business Name): KENDALL P. TABOR, D.P.M
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2008
Last Update Date: 12/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 W FAIR AVE STE 215
MARQUETTE MI
49855-2675
US

IV. Provider business mailing address

1414 W FAIR AVE STE 215
MARQUETTE MI
49855-2675
US

V. Phone/Fax

Practice location:
  • Phone: 906-225-7709
  • Fax: 906-225-7707
Mailing address:
  • Phone: 906-225-7709
  • Fax: 906-225-7707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number5901001089
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number5901001089
License Number StateMI

VIII. Authorized Official

Name: DR. KENDALL P TABOR
Title or Position: OWNER/PODIATRIST
Credential: D.P.M.
Phone: 906-225-7709