Provider Demographics
NPI:1770152761
Name:KOBERNUSZ, MARILYN MARIE
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:MARIE
Last Name:KOBERNUSZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARILYN
Other - Middle Name:MARIE
Other - Last Name:LAMPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:43318 SD HIGHWAY 38
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:SD
Mailing Address - Zip Code:57374-5403
Mailing Address - Country:US
Mailing Address - Phone:605-421-1818
Mailing Address - Fax:
Practice Address - Street 1:43318 SD HIGHWAY 38
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:SD
Practice Address - Zip Code:57374-5403
Practice Address - Country:US
Practice Address - Phone:605-421-1818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician