Basic Information
Provider Information
NPI: 1194701946
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DAMBACHER
FirstName: KENNETH
MiddleName: EUGENE
NamePrefix: DR.
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 129
Address2:  
City: YALE
State: MI
PostalCode: 48097
CountryCode: US
TelephoneNumber: 8103872175
FaxNumber: 8103784905
Practice Location
Address1: 251 E PECK RD
Address2:  
City: PECK
State: MI
PostalCode: 484669589
CountryCode: US
TelephoneNumber: 8103784900
FaxNumber: 8103784905
Other Information
ProviderEnumerationDate: 12/22/2005
LastUpdateDate: 07/08/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: X
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X5101008768MIY Allopathic & Osteopathic PhysiciansFamily Medicine 

ID Information
IDTypeStateIssuerDescription
085760042401MIBLUE CROSS BLUE SHIELD MIOTHER


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