Provider Demographics
NPI:1265092589
Name:DEBOLT, MARI I
Entity type:Individual
Prefix:
First Name:MARI
Middle Name:I
Last Name:DEBOLT
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 1:123 N PINE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MI
Mailing Address - Zip Code:48880-1428
Mailing Address - Country:US
Mailing Address - Phone:989-721-0857
Mailing Address - Fax:
Practice Address - Street 1:123 N PINE ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-1428
Practice Address - Country:US
Practice Address - Phone:989-721-0857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-18
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1934415146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1934415OtherEMERGENCY MEDICAL TECHNICIAN LICENSE