Provider Demographics
NPI:1629592068
Name:HIBMA, LEVI JOHN
Entity Type:Individual
Prefix:
First Name:LEVI
Middle Name:JOHN
Last Name:HIBMA
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 1:5985 RICE CREEK PKWY STE 104
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-5036
Mailing Address - Country:US
Mailing Address - Phone:651-484-6735
Mailing Address - Fax:
Practice Address - Street 1:5985 RICE CREEK PKWY STE 104
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-5036
Practice Address - Country:US
Practice Address - Phone:651-484-6735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10669225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist