Provider Demographics
NPI:1982351128
Name:THEIS, REBECCA
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:THEIS
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:PO BOX 643
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837
Mailing Address - Country:US
Mailing Address - Phone:517-898-5461
Mailing Address - Fax:
Practice Address - Street 1:913 CANDELA LN
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-2240
Practice Address - Country:US
Practice Address - Phone:517-898-5461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-08
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIT200734261417343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)