Provider Demographics
NPI:1255990552
Name:KBOOSE
Entity type:Organization
Organization Name:KBOOSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-228-3324
Mailing Address - Street 1:3008 JUNEBERRY AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1523
Mailing Address - Country:US
Mailing Address - Phone:616-228-3324
Mailing Address - Fax:
Practice Address - Street 1:3008 JUNEBERRY AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-1523
Practice Address - Country:US
Practice Address - Phone:616-228-3324
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty