Provider Demographics
NPI:1891838694
Name:KIEKOVER, ANGELA K (PT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:K
Last Name:KIEKOVER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 MICHIGAN AVE
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-4951
Mailing Address - Country:US
Mailing Address - Phone:616-355-4284
Mailing Address - Fax:616-355-4285
Practice Address - Street 1:601 MICHIGAN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-4951
Practice Address - Country:US
Practice Address - Phone:616-355-4284
Practice Address - Fax:616-355-4285
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501012402225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5501012402OtherMI STATE LICENSE
MI65-0-G0-1466-0OtherBCBSM
MIN74750009Medicare PIN
MI65-0-G0-1466-0OtherBCBSM
MIN51840011Medicare PIN