Healthcare Provider Details

I. General information

NPI: 1558554949
Provider Name (Legal Business Name): KIM OGE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 E BROADWAY RD STE. 100
TEMPE AZ
85282-1599
US

IV. Provider business mailing address

1025 E BROADWAY RD STE. 100
TEMPE AZ
85282-1599
US

V. Phone/Fax

Practice location:
  • Phone: 480-829-0217
  • Fax: 480-829-1410
Mailing address:
  • Phone: 480-829-0217
  • Fax: 480-829-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number629
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: