Provider Demographics
NPI:1104255843
Name:LUBERISSE, ANNEX (ND)
Entity type:Individual
Prefix:
First Name:ANNEX
Middle Name:
Last Name:LUBERISSE
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1674 S ODELL AVE # B
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-3365
Mailing Address - Country:US
Mailing Address - Phone:660-229-0858
Mailing Address - Fax:
Practice Address - Street 1:1674 S ODELL AVE # B
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340-3365
Practice Address - Country:US
Practice Address - Phone:660-229-0858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710320643OtherNPI
MA4558OtherPTAN