Provider Demographics
NPI:1457622623
Name:LABERGE, WILLIAM
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:LABERGE
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 1:7810 W 85TH ST APT B
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66212-1900
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 E FLAMING RD
Practice Address - Street 2:
Practice Address - City:OLATHE
Practice Address - State:KS
Practice Address - Zip Code:66061-5343
Practice Address - Country:US
Practice Address - Phone:913-829-2273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-02031314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility