Provider Demographics
NPI:1114756756
Name:KASSUBA, VALERIE
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:KASSUBA
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 374
Mailing Address - Street 2:
Mailing Address - City:JOHANNESBURG
Mailing Address - State:MI
Mailing Address - Zip Code:49751-0374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 EDELWEISS VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-7441
Practice Address - Country:US
Practice Address - Phone:989-732-5233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI228189156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician