MEDICARE: BRENDA KIBOLA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	68970	WI

General Provider Information

NPI Number	:	1821415795
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA KIBOLA MD

Provider Business Mailing Address
First Line	:	PO BOX 473
Second Line	:
City	:	RICE LAKE
State	:	WI
Zip	:	54868-0473
Country	:	US
Telephone Number	:	715-317-5466
Fax Number	:

Provider Business Practice Location Address
First Line	:	2004 HIGHLAND AVE STE 2B
Second Line	:
City	:	EAU CLAIRE
State	:	WI
Zip	:	54701-4389
Country	:	US
Telephone Number	:	715-317-5466
Fax Number	:	866-728-0304

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2014
Last Update Date	:	04/11/2024

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