Provider Demographics
NPI:1669777439
Name:MATHIS, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MATHIS
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 1:37578 FOUNTAIN PARK CIR
Mailing Address - Street 2:APT 428
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-5627
Mailing Address - Country:US
Mailing Address - Phone:734-459-8010
Mailing Address - Fax:
Practice Address - Street 1:37578 FOUNTAIN PARK CIR
Practice Address - Street 2:APT 428
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48185-5627
Practice Address - Country:US
Practice Address - Phone:734-459-8010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM320469585696343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)