Provider Demographics
NPI:1558871525
Name:MADISON, KHESON KABALLA
Entity Type:Individual
Prefix:
First Name:KHESON
Middle Name:KABALLA
Last Name:MADISON
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 1:555 W GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:WISCONSIN RAPIDS
Mailing Address - State:WI
Mailing Address - Zip Code:54495-2784
Mailing Address - Country:US
Mailing Address - Phone:715-424-4682
Mailing Address - Fax:715-424-4614
Practice Address - Street 1:555 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:WISCONSIN RAPIDS
Practice Address - State:WI
Practice Address - Zip Code:54495-2784
Practice Address - Country:US
Practice Address - Phone:715-424-4682
Practice Address - Fax:715-424-4614
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2403-19225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant