Healthcare Provider Details

I. General information

NPI: 1063500700
Provider Name (Legal Business Name): DALE ANTHONY KIRBY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 ANDERSON STATE ROAD
FAYETTEVILLE OH
45118
US

IV. Provider business mailing address

PO BOX 141
FAYETTEVILLE OH
45118-0141
US

V. Phone/Fax

Practice location:
  • Phone: 937-205-2337
  • Fax: 513-875-2811
Mailing address:
  • Phone: 937-205-2337
  • Fax: 513-875-2811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number2291023
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: