Provider Demographics
NPI:1063500700
Name:KIRBY, DALE ANTHONY
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:ANTHONY
Last Name:KIRBY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 141
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45118-0141
Mailing Address - Country:US
Mailing Address - Phone:937-205-2337
Mailing Address - Fax:513-875-2811
Practice Address - Street 1:62 ANDERSON STATE ROAD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:OH
Practice Address - Zip Code:45118
Practice Address - Country:US
Practice Address - Phone:937-205-2337
Practice Address - Fax:513-875-2811
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2291023171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2291023Medicaid