Provider Demographics
NPI:1205397890
Name:KISS ENT LLC
Entity Type:Organization
Organization Name:KISS ENT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:M
Authorized Official - Last Name:GANT
Authorized Official - Suffix:II
Authorized Official - Credentials:LPN
Authorized Official - Phone:616-272-6896
Mailing Address - Street 1:2908 GIDDINGS AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1430
Mailing Address - Country:US
Mailing Address - Phone:616-272-6896
Mailing Address - Fax:
Practice Address - Street 1:2908 GIDDINGS AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-1430
Practice Address - Country:US
Practice Address - Phone:616-272-6896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-27
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
No251E00000XAgenciesHome Health