Provider Demographics
NPI:1437717774
Name:KIKOMBE, KASKILE
Entity Type:Individual
Prefix:
First Name:KASKILE
Middle Name:
Last Name:KIKOMBE
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 1:2410 LAKESIDE DR APT 7
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52240-6802
Mailing Address - Country:US
Mailing Address - Phone:319-594-6837
Mailing Address - Fax:
Practice Address - Street 1:1705 S 1ST AVE STE A
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52240-6037
Practice Address - Country:US
Practice Address - Phone:319-594-6837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-02
Last Update Date:2019-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA588399343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)