Provider Demographics
NPI:1245254762
Name:BUSSURE, KIMBERLY
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:
Last Name:BUSSURE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1178 S LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-3042
Mailing Address - Country:US
Mailing Address - Phone:810-664-2727
Mailing Address - Fax:810-667-2727
Practice Address - Street 1:1178 S LAPEER RD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-3042
Practice Address - Country:US
Practice Address - Phone:810-664-2727
Practice Address - Fax:810-667-2727
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5650010001Medicare NSC