Provider Demographics
NPI:1750693123
Name:URETA, KIMBERLY LAIN (CMT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:LAIN
Last Name:URETA
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9179 G AVE
Mailing Address - Street 2:
Mailing Address - City:HESPERIA
Mailing Address - State:CA
Mailing Address - Zip Code:92345-6121
Mailing Address - Country:US
Mailing Address - Phone:760-646-3140
Mailing Address - Fax:
Practice Address - Street 1:17685 1/2 VERDE ST
Practice Address - Street 2:
Practice Address - City:HESPERIA
Practice Address - State:CA
Practice Address - Zip Code:92345-5442
Practice Address - Country:US
Practice Address - Phone:760-646-3140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-13
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist