Provider Demographics
NPI:1174142442
Name:HOUSE, KIM
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:HOUSE
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 1:4635 PINE DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-8922
Mailing Address - Country:US
Mailing Address - Phone:616-610-1204
Mailing Address - Fax:
Practice Address - Street 1:955 S BAILEY AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-6743
Practice Address - Country:US
Practice Address - Phone:269-639-2779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-15
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI877154133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered