Provider Demographics
NPI:1073929089
Name:LDK III HOLDINGS, LLC
Entity Type:Organization
Organization Name:LDK III HOLDINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:DUSTIN
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:III
Authorized Official - Credentials:DO
Authorized Official - Phone:517-437-0010
Mailing Address - Street 1:451 HIDDEN MEADOWS DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:HILLSDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49242-9812
Mailing Address - Country:US
Mailing Address - Phone:517-437-0010
Mailing Address - Fax:517-437-0319
Practice Address - Street 1:451 HIDDEN MEADOWS DR
Practice Address - Street 2:SUITE 120
Practice Address - City:HILLSDALE
Practice Address - State:MI
Practice Address - Zip Code:49242-9812
Practice Address - Country:US
Practice Address - Phone:517-437-0010
Practice Address - Fax:517-437-0319
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101010860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty